HealthCare Industry News Trends

Technologies Solutions Group (TSG) has been tracking emerging trends and direction of the Healthcare industry for the last 4 years. We use a variety of search engines directly catering to Healthcare to not only position our products effectively but design them to meet the emerging needs of the Healthcare environment. We invite you to review these articles by leading healthcare professionals and organizations to familiarize yourself with the latest movements in the market.

Pennsylvania Hospitals Charged $1.25B to Treat Infection-Related Readmissions

Analysis of Pennsylvania Health Care Cost Containment Council data by the Pittsburgh Tribune-Review found that in 2009, Pennsylvania hospitals charged more than $1.25 billion to treat readmissions due to avoidable infections or complications, according to a Tribune-Review report.University of Pittsburgh Medical Center’s Presbyterian and Shadyside hospitals spent $67 million — the most charges in Pennsylvania for infection-caused readmissions in 2009. Sixteen of the 20 highest-charging hospitals were from Philadelphia and its suburbs, according to the report.The condition that produced the highest charges was congestive heart failure, accounting for more than $174 million.The report said that although presently hospitals are financially incentivized to readmit patients, they will no longer receive reimbursements from Medicare and Medicaid for hospital-acquired infections starting in 2012, which may cause them to focus on reducing readmissions.

Medicare/Medicaid Withholdings and fines 

The conditions identified by CMS would not be recognized for payment for discharges occurring on or after October 1, 2008 (FFY 2009) if they were acquired during the patient’s stay.The first eight conditions, which were selected in 2007 because they greatly complicate the treatment of the illness or injury that caused the hospitalization, resulting in higher payments to the hospital for the patient’s care by both Medicare and the patient were:

  • Object inadvertently left in after surgery
  • Air embolism
  • Blood incompatibility
  • Catheter associated urinary tract infection
  • Pressure ulcer (decubitus ulcer)
  • Vascular catheter associated infection
  • Surgical site infection-Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
  • Certain types of falls and traumas

2008 Additions

  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity
  • Certain manifestations of poor control of blood sugar levels
  • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures.

The Centers for Medicare and Medicaid Services (CMS) has titled the program “Hospital-Acquired Conditions and Present on Admission Indicator Reporting” (HAC) and published rules August 22, 2007[5] revising the Medicare hospital inpatient prospective payment system (IPPS) to implement changes in the reimbursement system based on these identified conditions. Medicaid payments were not addressed in the rule. Beginning October 1, 2007, IPPS hospitals were required to submit present on admission (POA) information on inpatient claims. CMS will begin the new payment policy on October 1, 2008.

The rational for the use of POA indicators according to the Healthcare Cost and Utilization Project (H-CUP) is that it will distinguish pre-existing conditions from complications and help to improve the design and fairness of pay-for-performance programs. CMS estimates the federal government will realize savings of $50 million per year for the first three years beginning October 1, 2008. Beginning in FY 2012, they estimate savings of $60 million per year.

Before states institute changes in their reimbursement strategies, several variables must be considered. The Joint Commission on Accreditation of Healthcare Organizations contends that a policy of withholding payment for adverse events is reasonable if certain conditions exist:

1. Evidence that the bulk of the adverse events in question can be prevented by widespread adoption of achievable practices.

2. The events can be measured accurately, in a way that is auditable.

3. It is possible, through chart review, to differentiate the adverse events that began in the hospital from those that were “present on admission” (POA)

VA hospitals and Hand Hygiene

Health care infections cause 50 percent of major hospital complications, and the No. 1 carrier of those infections is the staff. As it turns out, only four in 10 workers follow recommended hand cleaning procedures. The Veterans Affairs Department decided to clean up the problem in its 158 hospitals with a campaign encouraging workers, volunteers, visitors and patients to cover their coughs and sneezes, wear gloves, and for Pete’s sake, wash their hands!The “Infection: Don’t Pass It On” campaign started last fall out of the VA’s National Center for Patient Safety, Employee Education System and a group of infection control experts. Its Web site, www.publichealth.va.gov/infectiondontpassiton, features 60 downloadable posters, templates for buttons and information about ordering pins, CDs, pens, lanyards and even tissue dispensers.VA’s effort promotes the use of alcohol- based hand rubs before and after touching patients. It also urges patients and visitors to keep an eye on hospital staff : “It’s OK to ask health care providers if they have cleaned their hands,” says one poster available in English and Spanish.An informal survey sent to VA hospital staff earlier this year suggests the campaign is having an effect – 53 percent of respondents said they washed their hands more often as a result of the campaign. Nearly 60 percent said they had seen their colleagues at the sink more often. Three percent said they soaped up 100 percent more often than before. That alone was worth the effort!

Hand Sanitation

U.S. healthcare facilities are grossly underperforming in hand hygiene compliance, which could impact healthcare-associated infections and patient safety, said two of the world’s foremost experts on infection prevention and hand hygiene.Speaking last week before more than 200 healthcare leaders at a hand hygiene forum organized by Loyola University Medical Center and Medline Industries, Inc., at Loyola’s Strich School of Medicine in Maywood, Ill., professor Didier Pittet, MD, director of the infection control program at the University of Geneva, Switzerland, and Mark R. Chassin, MD, FACP, MPP, MPH, president of the Joint Commission, cited time constraints, product misconceptions and faulty data as main reasons for the country’s poor hand hygiene compliance, but also offered hope for improvement.

The Joint Commission Center for Transforming Healthcare tackled the issue of hand hygiene compliance as its first project, according to Chassin. The participating organizations were surprised to learn that their rate of hand hygiene compliance averaged 48 percent.”These healthcare organizations had the courage to step forward to tackle the problem of hand washing by digging deep to find out where the breakdowns were taking place so we could create targeted solutions,” Chassin says. “We are very optimistic since the original facilities participating in the project have seen their average compliance increase to 81 percent and have sustained that level for 10 months.

”Other reasons for poor compliance, according to Pittet, is lack of time by healthcare workers to perform hand hygiene and misinformation on what type of product is most effective – soap and water, alcohol-based hand sanitizers or foams.“The problem with soap and water is that it takes anywhere from one to one-and-a-half minutes to perform proper hand hygiene. If workers wash their hands 15-20 times in an hour, that would take about half an hour, which is totally unrealistic. Also, after several washings, your hands will become dry and chapped,” says Pittet. “Alcohol-based hand rubs take only 15 to 30 seconds, they’re also more effective than soap and water, better for your hands and more convenient because you can carry them around with you.”

Pittet, a member of the Advisory Board of the World Health Organization (WHO) World Alliance for Patient Safety, also emphasized that there is no evidence in the current published literature that supports the effectiveness for foam-based hand hygiene products. However, he strongly suggests using alcohol-based hand rubs with at least 80 percent ethanol – a significantly higher percentage than 62 percent ethanol, commonly used by U.S. facilities, which is at the low end of the CDC recommendation.

“It’s hard to believe that there have been so many products that have been used in the United States that will never pass the European norms,” says Pittet. “So some of the products that you are using in the United States have not made it to the European market, because they just don’t meet the norms.”

According to Chassin, the solutions developed by the original organizations participating in the Center for Transforming Healthcare’s hand hygiene project are now available via the Center’s Targeted Solutions Tool™ (TST), a complimentary data-driven application. The solutions are validated and customized to address an organization’s particular barriers to excellent performance. Use of the tool is self- paced, confidential, and offers instantaneous data analysis.

Chassin said the good news is that more healthcare facilities are focusing major efforts on hand hygiene compliance. He cited that more than 1,500 projects at 900 organizations are now using the Center for Transforming Healthcare’s hand hygiene TST.

HAI Penalties

AHA wants more clarity on hospital-acquired penaltiesBy Ron Shinkman
Created Mar 22 2011 – 2:13pmThe American Hospital Association is seeking more clarity regarding guidelines for payment denials related to conditions acquired in a healthcare setting, reports AHA News.Although the Centers for Medicare and Medicaid Services is allowed to prohibit payments to providers for hospital-acquired infections and complications stemming from medical errors, state agencies are allowed leeway in determining these conditions. The AHA is concerned that the CMS may be overstepping guidelines under the Patient Protection and Affordable Care Act to prohibit payments by not focusing on what it calls a “core set of healthcare-acquired conditions.”Of particular concern are multi-state systems. “If states are able to finalize completely different lists of healthcare-acquired conditions, it would be extremely difficult to manage across a health system,” said AHA Executive Vice President Rick Pollack in a letter to CMS Director Donald M. Berwick.

To prevent such an overreach, the primary lobbying group for non-profit hospitals wants a clear list of healthcare-acquired conditions that would lead to a payment prohibition.

The AHA also expressed apprehensions over the lack of a risk-adjustment mechanism, which could prevent hospitals from defending themselves for an improper penalty, according to Pollack.

CMS Program targets hospital-acquired infections

The Centers for Medicare & Medicaid Services (CMS) today announced the launch of “Partnership for Patients,” an initiative targeting hospital-acquired infections. CMS is part of the U.S. Department of Health & Human Services (HHS).The program’s goal is to improve care delivery and outcomes in “two key areas,” Excellus BlueCross BlueShield (BCBS), Central New York’s largest health insurer, said in a news release.The program aims to reduce the rate of health care-associated infections 40 percent by the end of 2013.Its other goal is to reduce “avoidable” hospital readmissions within 30 days of discharge by 20 percent compared by the end of 2013, Excellus said. To achieve the goals, CMS in 2012 wants “a growing portion of the [Medicare] payment adjusted based on the hospital’s performance,” according to Excellus.By 2015, CMS could base 9 percent of a hospital’s Medicare payment on whether it’s meeting the program goals, delivering safer care, and using information-technology effectively, according to HHS.
To launch the program, HHS said it would invest up to $1 billion in funding through the federal health-care reform law, according to its website. Excellus BCBS in 2007 issued a “fact sheet” on hospital-acquired infections.

It estimated 19,500 upstate New Yorkers acquired an infection during a hospital stay in 2004 and nearly 1,000 deaths were likely to have occurred as a result.

Preventing MRSA in healthcare – Is there a silver bullet?

April 13th, 2011 5:02 pm ET – .John Jernigan, M.D.John Jernigan, M.D
Director for CDC’s Office of HAI Prevention Research and Evaluation, Division of Healthcare Quality PromotionThe optimal approach to controlling MRSA in healthcare facilities has been a topic of ongoing controversy. Of particular interest is the question of whether the use of active detection and isolation of patients colonized with MRSA, also known as ADI, should be routinely used. Despite ongoing research and vigorous scientific debate, a simple answer has remained elusive. This week, two studies were published in the New England Journal of Medicine that illustrate the complexities of the scientific evidence surrounding ADI. One of these studies, the STAR*ICU Trial (Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care), found that ADI as implemented in the study was not effective in reducing transmission of MRSA or VRE. A separate observational study (“Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections“) involving the entire national VA hospital system, found that after implementing a multifaceted MRSA prevention program that included ADI, MRSA transmissions and HAIs decreased significantly. The fact that these studies seem to give different answers illustrates the challenge we as scientists face in making recommendations on how best to use limited prevention resources-sometimes the answers aren’t simple as we would like.I do think there are some lessons we can take away from these studies. Together, the study findings are consistent with current belief that MRSA is too complex a problem to be controlled with any single intervention. The VA study suggests that MRSA can be effectively controlled, even on a large scale involving hundreds of hospitals, using a multifaceted intervention strategy. While the strategy chosen by the VA did include use of ADI, the study design does not allow an assessment of the individual contribution of ADI to the overall success.

So what’s the bottom line? The most important message from these studies is that MRSA control, while difficult, is achievable, even if experts may still argue about the best way to do it. In light of the conflicting evidence on the optimal role of ADI, some hospitals may choose strategies that do not include it. Guidelines are available from CDC to help hospitals design an effective MRSA control program. But whatever strategy is chosen, rigorous measurement of the impact of the program should be in place, with the expectation that control of MRSA should be the result.

AHA wants more clarity on hospital-acquired penalties

AHA wants more clarity on hospital-acquired penaltiesBy Ron Shinkman
Created Mar 22 2011 – 2:13pmThe American Hospital Association is seeking more clarity regarding guidelines for payment denials related to conditions acquired in a healthcare setting, reports AHA News.

Although the Centers for Medicare and Medicaid Services is allowed to prohibit payments to providers for hospital-acquired infections and complications stemming from medical errors, state agencies are allowed leeway in determining these conditions. The AHA is concerned that the CMS may be overstepping guidelines under the Patient Protection and Affordable Care Act to prohibit payments by not focusing on what it calls a “core set of healthcare-acquired conditions.”Of particular concern are multi-state systems. “If states are able to finalize completely different lists of healthcare-acquired conditions, it would be extremely difficult to manage across a health system,” said AHA Executive Vice President Rick Pollack in a letter to CMS Director Donald M. Berwick.

To prevent such an overreach, the primary lobbying group for non-profit hospitals wants a clear list of healthcare-acquired conditions that would lead to a payment prohibition.The AHA also expressed apprehensions over the lack of a risk-adjustment mechanism, which could prevent hospitals from defending themselves for an improper penalty, according to Pollack.

Hand Washing Legislation

Advocates ask hand washing be part of Nevada safety bill

Written b yFrank X. Mullen12:00 AM, May. 6, 2011

A state Senate committee Thursday heard testimony but took no action on a bill requiring safety checklists in hospitals, after hearing pleas from patient-safety advocates to restore a mention of hand-washing as an option for sanitizing the hands of health care workers.Assembly Bill 280 would require safety checklists and patient safety policies at hospitals and other health care facilities. Assembly lawmakers this month passed the bill after removing language that mandated health workers “wash their hands before and after every interaction with a patient and after coming into contact with a surface or object that may be contaminated.”
Instead, AB 280 now refers to proper “hand hygiene,” a term that the bill’s sponsor and health care industry lobbyists said encompasses all types of hand hygiene, including soap and water.

Assembly Speaker John Oceguera, D-Las Vegas, the bill’s sponsor, told the state Senate Health and Human Services Committee that the bill’s language is meant to be broad enough to include all the various hand sanitation methods used at hospitals.

But Barry Gold of the Nevada Chapter of the American Association of Retired People testified that in his experience, hand hygiene rules are often ignored by heath care workers. He said the proposed amendment would recognize that hand washing is just one of the acceptable methods of keeping patients safe from hospital-acquired infections.

State Sen. Joseph Hardy, R-Boulder City, a physician, opposed mentioning hand washing in the bill. He said he has read studies that conclude “washing with soap and water creates more problems than it protects.” He said newer technologies, such as alcohol gels, are available for hand sanitation.

The Scary Math of Hospital Infections

Two infections kill 65,000 patients per year(CNN) – A column in yesterday’s New York Times by Maureen Dowd about how her brother died after acquiring infections in the hospital certainly struck a nerve – it was No. 1 on the paper’s website for much of the day.No wonder, considering the number of people who die of infections as her brother did.“The simplest way to say this is that about 100,000 people die each year from infections we give them in the hospital,” says Dr. Peter Pronovost, director of the Quality and Safety Research Group at Johns Hopkins University. “That’s enormous.”The math, he says, is pretty gruesome. Take the two most deadly types of infections hospitals give their patients: infections from ventilators and infections from catheters. Together, those kill 65,000 people a year. There are about 5,000 hospitals in the United States, so statistically, each hospital in the United States gives these deadly infections to one patient every month.In her column, Dowd described how her brother went into the hospital with pneumonia and quickly contracted four other infections in the intensive care unit. When she asked a doctor why this was happening, he told her, “It could be anything.’”

This is exactly the kind of attitude that’s killing patients, Pronovost says.

“What really struck me most in Maureen’s column was the physician’s lack of accountability,” he explains. “He didn’t see this as his problem. It was like, ‘Well, this stuff happens.’”

Pronovost says the doctor viewed hospital-acquired infections as being in the “inevitable bucket” when really they’re in the “preventable bucket.” He says when hospitals have taken simple steps they’ve managed to reduce pneumonia infections associated with ventilators by 70%.

He says there are two particularly important things families can do when a loved one is in the hospital. One, they should ask everyone who comes in contact with the patient to wash his or her hands. Two, if the patient is on a catheter or a ventilator, they should ask every day if it can come out, since these pieces of equipment are ripe locations for infections.

Feds Post Database of Hospital Errors

Denver Business Journal – by Corrinne Hess | The Business Journal of MilwaukeeTo the dismay of the American Hospital Association, the Centers for Medicare and Medicaid Services has released an exhaustive list of medical errors occurring at the nation’s 4,700 hospitals.The CMS database of eight categories of “hospital-acquired conditions” includes leaving a foreign object in the body after surgery, urinary tract infections caused by a catheter, and pressure sores. It compares each error to the national rate for the event in question.The information is offered online through the U.S. Department of Health and Human Services‘ “Hospital Compare” website.Hospital-acquired conditions are “serious conditions that patients may get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions,” according to the HHS website.

In addition to the loss of life and medical harm to patients, such errors add to the cost of health care.

CMS used Medicare fee-for-service claims from October 2008 through June 2010.

A study by the Institute of Medicine of The National Academy of Sciences in Washington concluded medical errors add significantly to Medicare hospital payments, ranging from an average of an additional $700 per case to treat bedsores to $9,000 per case to treat post-operative sepsis.

Another Institute of Medicine study concluded that medical errors may account for 2.4 million extra hospital days, and $9.3 billion in excess charges for all payers.

In October 2008, Medicare stopped reimbursing health care providers for the extra costs of treating preventable injuries and infections that occur while a patient is in the hospital.

The data originally was scheduled to be published in September 2010, but it was met with strong resistance from hospital groups.

“Hospitals continue to urge CMS not to publish these data,” read a March 31 joint statement from the AHA, the Federation of American Hospitals and the Association of American Medical Colleges.

Nursing Homes Infection Control Violations
STUDY FINDS INFECTION CONTROL VIOLATIONS AT 15 PERCENT OF U.S. NURSING HOMES

Washington, May 3, 2011 – Fifteen percent of U.S. nursing homes receive deficiency citations for infection control per year, according to a new study published in the May issue of the American Journal of Infection Control, the official publication of APIC – the Association for Professionals in Infection Control and Epidemiology.Conducted by a team of researchers at the University of Pittsburgh’s Graduate School of Public Health, the study analyzed deficiency citation data collected for the purpose of Medicare/Medicaid certification between 2000 and 2007, representing approximately 16,000 nursing homes per year and a panel of roughly 100,000 observations. The records analyzed represent 96 percent of all U.S. nursing home facilities. The team discovered a strong correlation between low staffing levels and the receipt of an infection control deficiency citation.Infections are the leading cause of morbidity and mortality in nursing homes, responsible for nearly 400,000 deaths per year. Although this has been the focus of mainstream media attention, very little empirical research has been conducted on the subject.The Centers for Medicare and Medicaid Services (CMS) requires that nursing homes be certified before receiving reimbursement for Medicare and/or Medicaid residents. As part of this certification process, facilities that do not meet certain standards are issued deficiency citations. This study examined the deficiency citation for infection control requirements known as the F-Tag 441.
“Our analysis may provide some clues as to the reason for the persistent infection control problems in nursing homes,” state the authors. “Most significantly, the issue of staffing is very prominent in our findings; that is, for all three caregivers examined (i.e., nurse aides, LPNs and RNs) low staffing levels are associated with F-Tag 441 citations. With low staffing levels, these caregivers are likely hurried and may skimp on infection control measures, such as hand hygiene.”

The authors conclude, “The high number of deficiency citations for infection control problems identified in this study suggests the need for increased emphasis on these programs in nursing homes to protect vulnerable elders.”

A number of states have enacted legislation that applies to infection prevention practices in long-term care facilities. Illinois is poised to pass legislation requiring an infection preventionist in each skilled nursing facility.

(AJIC 2011; 39 [5])

Visitor Tracking

Visitors can reduce hospital-acquired infections by washing hands

At any given time, one in 20 patients in the U.S. has a hospital-acquired infection.Hospital-acquired infections cost the health care system billions of dollars each year, and lead to the loss of tens of thousands of lives.Nearly 20 patients in Wisconsin hospitals each week get bloodstream infections from the central lines used to deliver fluids, medication and blood. Two to four of them will die.The U.S. Department of Health and Human Services aims to bring the numbers down, and Friday unveiled a new interactive tool that anyone with a computer can access to help reduce hospital-acquired infections.
The interactive computer based video-simulation follows five main characters: a patient’s family member, a nurse, a physician, a third-year medical student and an infection preventionist. The introduction dramatizes mistakes made while caring for a college student who is recovering from an appendectomy. Because infection control practices aren’t followed, the student develops an infection and dies.

A second case in the video simulation involves a woman visiting her father after surgery, who fails to wash her hands before entering and leaving his room.

Those watching the video assume the identity of the characters and make decisions as each of those characters. Based upon their decisions, the training branches to different pathways and patient outcomes. The scenes demonstrate worst-case scenarios of how lapses in medical judgment, communication, teamwork, and attention to infection control practices may impact patient outcomes.

The tool also offers an infection prevention resource guide for patients and family members.

“Washing your hands with soap and warm water, or using an alcohol-based hand rub, will remove 99% of germs that can lead to harmful and potentially deadly infections,” notes the video segment involving a patient’s family member. “All patients in a hospital are at risk for infections, and patients that are seriously ill or have recently had surgery are more vulnerable.”

MRSA Impacts Building Trends

Nearly all the 240 in-patient rooms in the medical tower are single-patient rooms.These types of features are about more than aesthetics, said Erickson, of the American Society for Healthcare Engineering. He also is chairman of a national nonprofit group that writes construction guidelines for hospitals and other medical facilities.Hospitals have evolved into a more hotel-like environment, he said, such as having single rooms to promote rest and privacy.“You’re not in a room where the other patient is moaning and groaning or family members are coming in and wanting to have a party because they’re going home,” he said.High noise levels have been shown to increase blood pressure, and heart and respiratory rates, according to a 2008 study the Journal of the American Medical Association.

Studies have found other benefits for single-bed rooms, cutting back on medication errors, patient falls, and bacterial infections such as MRSA, Erickson said.

“In a semi-private room, there’s a direct correlation — if your roommate’s got it, there’s a very good possibility you’ll come down with MRSA,” he said.

The costs of treating patients for hospital-acquired infections are shifting more to hospitals.

The financial stakes are high. A recent federal study found that on average, a typical hospitalization costs about $9,377 dollars. The cost of treating a patient with a hospital-acquired infection can cost about $43,000.

A quieter environment and more family interaction with patients have been found to speed recovery and decrease a patient’s hospitalization by 12 to 18 hours, Erickson said.

With a typical hospital stay averaging about three days, reducing it by even a half day not only makes for happier patients, it can have big financial impacts, he said.

For all these reasons, features such as single-bed patient rooms pay for themselves over the years a medical building is in use, Erickson said.

Historically, hospitals have transitioned from 30-bed wards to rooms with eight beds, then four, then two. “Then we really got smart,” he said. “The reason why we’re getting out of 1970s-vintage buildings is they were truly built like institutions.”

Some people may look at the big, new hospital buildings springing up across the nation and wonder: “Why are we building these Taj Mahals?” Erickson said. “You don’t have to be an accounting major to figure this one out.”

100,000 Lives Lost Each Year Due to Dirty Hospitals

100,000 Lives Lost Each Year Due to Dirty Hospitals and Nursing HomesBy Catherine Bertram
05-16-2011Each year 100,000 patients in hospitals and nursing homes in this country die from infection they acquired after being in a health care facility. This is the most common complication of hospital care and also one of the deadliest risks for patients according to government officials.

In addition the loss of lives, the cost for our health care system isenormous. The estimated annual cost for hospital acquired infections is between $28 and $33 billion.What is even more shocking and tragic is that the consensus in the US medical community is that most of these infections are preventable. How you ask? This is really where it should make us all angry – by washingyour hands in between patients. It is not expensive or dangerous to implement. What will it take to make hospitals and nursing homes clean up their act? Unfortunately, it has to hit them where it hurts – in their pocket book. In 2008, the Centers for Medicare and Medicaid (CMS) began denying payments to hospitals for the costs of patient’s care and patient days related to these infections.

If you want more information about hospital acquired infections you can look at the Centers for Disease Control (CDC) website which provides links to infection prevention materials, statistics on infection rates and other materials.

About the author:

Catherine Bertram is board certified in civil trials and was recently nominated again as a 2011 Best Lawyer in DC for Malpractice and a 2011 Super Lawyer for Washington, D.C. Ms. Bertram has over 20 years of trial experience and is unique in that she was formerly the Director of Risk Management for Georgetown University Hospital. Ms. Bertram is a member of the bar for the U.S. Supreme Court. She is a partner with the firm and lectures regularly to lawyers and health care providers, nationally and locally, regarding patient safety, medical negligence and other related issues. She has also recently published a chapter in a surgical textbook.

She can be reached by email at cbertram@reganfirm.com or by phone 202-822-1875 in her office in Washington, D.C

Poor Patient Safety is the New Code Word for High HAI Rates

Mercy Medical Center St. Mary’s told to address lapses St. Mary’s will lose Medicare funding if changes not made Mercy Health Partner’s 370-bed hospital in North Knoxville will lose its Medicare funding on June 5 if changes aren’t made to address patient safety issues found during an inspection by federal regulators.The decision by the federal Centers for Medicare & Medicaid Services to eliminate funding would affect seniors admitted for inpatient services at Mercy Medical Center St. Mary’s, located at 900 E. Oak Hill Ave.Mercy spokesman Craig Griffith said Thursday that the hospital does not intend to lose its Medicare funding.
“We have no reason to believe that Mercy St. Mary’s will lose any Medicare funding following this inspection. Mercy will take any steps necessary to remain in substantial compliance with all CMS regulations regarding Medicare, as our top priority is patient safety and providing outstanding health care to the Knoxville community,” Griffith said in a statement.

Medicare is a federal health insurance program for people age 65 or older. Hospitals receive reimbursement for services provided to Medicare patients.

While CMS spokeswoman Lee Millman could not speak specifically to the Mercy case because of confidentiality laws, she said such involuntary termination notices are issued because there is “a threat to patient health and safety.”

“It boils down to the delivery of quality care in a safe environment. Those are the two main parameters,” she said. “What happens if there is a deficiency in an area or areas is a termination notice can be sent.”

If the agreement with Mercy St. Mary’s is terminated, patients who are admitted to the hospital for inpatient services after June 5 will have to pay expenses out of pocket.

Mercy St. Mary’s, which has been treating patients since opening in 1930, may submit a correction plan, which has to be approved and subjects the hospital to an unannounced visit by inspectors.

“If everything has been remedied, then the termination notice can be lifted and the public would be notified,” Millman said.

It is rare for a facility to lose its funding, she added, because the Centers for Medicare & Medicaid Services works diligently with health care providers to make sure they meet the federal guidelines.

In 2010, nine hospitals in an eight-state region lost their funding, including two in Tennessee.

FDA Gets Deeper into Food Service

Poll Finds Most Americans Favor Increased Funding for Stronger Food Safety Oversight

Among likely voters surveyed across the nation, 66 percent support additional funding for the Food and Drug Administration (FDA) to carry out new responsibilities related to food safety, according to a Pew-commissioned poll released today by the bipartisan team of Hart Research and American Viewpoint.In addition, 74 percent feel it is worth a one-to-three percent increase in the cost of food to pay for new safety measures in the FDA Food Safety Modernization Act, which became law this year. Further, 70 percent of those surveyed favor food companies paying an average annual fee of $1,000 to help cover the cost of new FDA food safety activities.The survey also shows that a quarter of Americans “worry a great deal” about food being contaminated with bacteria that makes it unsafe to eat. Overall, 85 percent say the government should be responsible for ensuring that food is safe to eat and 71 percent of voters feel the FDA plays a “very important” or “essential” role in protecting Americans’ health and safety.The FDA Food Safety Modernization Act became law in January, strengthening the oversight authorities of the FDA. The legislation improves safety standards for food facilities and fresh produce, strengthens inspection requirements, boosts powers to help limit the dangers of food imports and provides the FDA with the power to issue a mandatory recall of contaminated food, among other authorities.

“For too long the FDA, which is responsible for the safety of over 80 percent of the foods we eat, has not had adequate resources or power to protect Americans from dangers in the food supply,” says Erik Olson, who directs food programs for the Pew Health Group. “This poll reflects a strong belief that Americans are willing to pay more to ensure that the FDA is protecting the safety of the food they put on their family’s dinner table.”

Those polled are widely in favor of the activities required under the new law. For example, 90 percent of voters favor requiring foreign countries that export food to the United States to certify that their requirements meet U.S. standards, and 86 percent support more FDA inspections of food facilities. Before the new law was enacted, the agency only examined about one percent of food imports and each facility received a visit from an FDA inspector on average once a decade.

Release of the survey comes as Congress is expected to consider legislation that will support the federal government for the next fiscal year.

WHO Hand-Hygiene Initiative Largely Ignored

May 20, 2011 (Milan, Italy) — Nearly half of healthcare professionals around the world fail to comply with the World Health Organization (WHO)’s Moment 1: Before Touching a Patient hand-hygiene initiative, according to a global WHO survey presented here at the 21st European Congress of Clinical Microbiology and Infectious Diseases.The hand-hygiene initiative is 1 of 5 measures, or “moments,” of Save Lives: Clean Your Hands (SLCYH), a global campaign launched by the WHO’s Clean Care is Safer Care program in an effort to promote sustained hand-hygiene improvement by registering medical facilities and providing guidance.“We all know that hand-hygiene compliance is very low; in general, compliance is only about 38.7%,” said lead author Benedetta Allegranzi, MD, from the WHO World Alliance for Patient Safety, in Geneva, Switzerland.“The 5 moments have become the gold standard for practicing and measuring hand hygiene around the world.”Moment 1 is among the most critical measures, she added. “We know Moment 1 — before touching the patient — is particularly important, as this indication protects patients from the powerful germs carried on healthcare workers’ hands after they touch other patients.”
In the first global survey on hand-hygiene compliance before patient contact, WHO collected data from 327 healthcare facilities registered with the SLCYH campaign, representing 47 countries and 1527 hospital wards.

The analysis showed that compliance with Moment 1 hand-hygiene in 76,803 hand-hygiene opportunities was just 51.4% (weighted mean adjusted by number of opportunities per facility).

Of those that were compliant, the hand-hygiene actions involved hand-rubbing in 60.7% of cases, hand-washing in 37.6% of cases, and both methods in 1.7% of cases.

The survey recommended that healthcare facilities collect approximately 50 hand-hygiene opportunities in selected wards or departments. Moment 1 hand-hygiene compliance was highest in European countries (64% of 22,278 opportunities) and lowest in the Americas (26% of 23,183 opportunities). Nurses showed much better compliance (64%) than physicians (48%).

Surprisingly, higher levels of hand-hygiene compliance were seen in ambulatory (72%), medical (60%), and intensive care (59%) departments; the lowest was seen in obstetrics departments (37%).

Limitations of the study include the short period of surveillance and the fact that the survey took place during a hand-hygiene awareness campaign, Dr. Allegranzi said. “Since this took place during the promotion of hand hygiene, levels of compliance can be expected to be higher than normal.”

According to Shira I. Doron, MD, MS, an assistant professor of medicine at Tufts University School of Medicine in Boston, Massachusetts, “before-care” compliance rates are commonly lower than “after-care” rates. Although experts believe that this is because of a prioritization of self-protection over protection of the patient, many healthcare workers might, in fairness, also believe that this will sanitize their hands for the next patient.

“In fact, we know that this is not true,” Dr. Doron explained. “If they’ve touched anything at all in between those 2 patients (computer keyboard, telephones, their own cellular phone, etc.), their hands are likely to be contaminated with microbes, and potentially antimicrobial-resistant ones.”

Antibiotic-resistant bacteria have indeed been isolated from such objects at Tufts, underscoring the importance of before-care hand hygiene, Dr. Doron added.

“If a healthcare worker washed before touching a patient every time, and never washed after touching a patient, there would be no transmission of microorganisms between patients on healthcare workers’ hands. So to patients, only the before-care hand hygiene really matters.”

Just as the evidence of low overall compliance is consistent with previous research, so is the finding of lower compliance rates among physicians than among nurses. With the pool of nurses typically made up of a larger proportion of women and the pool of physicians made up of a greater proportion of men, the discrepancy might be gender-related, Dr. Doron suggested.

“Research shows that women are more likely to perform hand hygiene than men, and that translates into better compliance by nurses than physicians, overall,” Dr. Doron said.

“Another theory is that nurses are often very strong patient advocates, prioritizing their patients’ needs over most other things in a way that physicians are not, and that leads to better hand hygiene to protect their patients.”

Hand-hygiene campaigns can help address the problem, but can also suffer from their own success as a sense of urgency wanes, Dr. Doron noted.

“Commonly, once success is achieved in hand hygiene, resources within the hospital are redirected to other important programs. As a result, hand-hygiene observations may be less frequent and less abundant, compliance rates may not be fed back to personnel as regularly as they had been, and incentive programs may be discontinued,” she said.

“The biggest challenge for institutions is, therefore, not how to improve hand-hygiene compliance, but how to maintain it in the face of the many other important patient safety goals that hospitals are focusing on these days.”

Hospitals Focus on Preventable Errors

Loss of reimbursement for ‘hospital acquired conditions’ adds bite to new figuresAs private and government health insurers continue to adapt tough reimbursement policies that withhold payments to medical care providers that make serious but preventable mistakes in patient care, new data released by the Centers for Medicare and Medicaid Services is shedding light on just how prevalent some of those incidents are at Connecticut hospitals.The numbers show Connecticut hospitals collectively reported a higher than average rate per 1,000 patient discharges of “hospital acquired conditions,” for four of the eight conditions tracked by CMS from October 2008 to June 2010, including foreign objects left in a patient after surgery.That occurred eight times in the state during the 18-month time period, including four times at Yale-New Haven Hospital, CMS data shows.Connecticut hospitals also collectively saw higher rates of catheter-related blood and urinary tract infections, as well as poor control of blood sugar for patients with diabetes. In-state medical providers had rates below the national average for conditions including patient falls, blood incompatibility, air embolisms, and pressure ulcers.
On an individual basis, many local hospitals rates lagged the national average.

CMS’s data, which reflect conditions that often result from improper procedures followed during inpatient care, is drawn from Medicare fee-for-service patients only.

Hospital officials have raised red flags about the data, questioning its relevancy and accuracy, but most agree transparency is a good thing.

They also have a financial incentive to reduce or eliminate the number of hospital acquired conditions, or HACs, that occur within their facilities.

Medicare and private insurance companies including Aetna are reducing or eliminating payments to medical care providers that make certain preventable errors.

Although not every HAC represents a medical error, some do putting pressure on hospitals to improve quality, or risk losing revenue.

“It’s getting people’s attention from a financial perspective,” said Dr. Jamie Roche, senior vice president for patient safety and quality at Hartford Hospital.

Roche said as payers begin to provide financial incentives or disincentives for hospital acquired conditions it’s helping the industry focus on rooting out certain frequent or avoidable mistakes.

Besides the potential harm to patients, medical errors add to the cost of health care, accounting for 2.4 million extra hospital days and $9.3 billion in excess charges for all payers annually, according to the Institute of Medicine of The National Academy of Sciences.

Roche said many hospitals are using evidence-based medicine to improve care quality and reduce costs. And a lot of the improvements are being driven by new technology and data tracking, which is helping to pinpoint problem areas.

One area Hartford Hospital has been working to improve is its hospital acquired bloodstream infections.

According to CMS data, out of 22,532 patient discharges from October 2008 to June 2010, Hartford Hospital experienced 14 vascular catheter-associated infections, for a rate of 0.621 per 1,000 patients. The national average during that time period was a rate of 0.367 per 1,000 patients.

By promoting better collaboration among all the players involved with the insertion, maintenance and withdrawal of a central line, and adopting a checklist to ensure proper evidence-based procedures are followed, the hospital has reduced those infections by a factor of six over the past two and a half years, Roche said.

Yale-New Haven Hospital experienced a higher than average rate per 1,000 patient discharges of hospital acquired conditions in five of the eight categories tracked by CMS. Out of 24,646 discharges, the hospital experienced 17 patient falls, 32 vascular catheter-associated infections and 17 catheter-associated urinary tract infections, CMS data shows.

Thomas J. Balcezak, vice president of performance management and associate chief of staff at Yale-New Haven Hospital, said he thought the numbers appear to be overinflated but he still believes the hospital needs to improve its performance.

Both Roche and Balcezak also expressed some concerns about the accuracy of the CMS data since it’s solely derived from billing records or medical claims, which may not be foolproof.

Another issue for Roche is that the numbers are not adjusted for hospitals’ patient populations or case-mix, which puts institutions that regularly care for people with more serious medical conditions at a disadvantage.

“It’s hard to compare one institution to another,” Roche said, “because there could be a variety of explanations for the differences.”

Regardless, the need to avoid hospital acquired conditions is something that is universally accepted among payers and providers in order to improve the quality of care and reduce costs.

That’s why Medicare began restricting reimbursements related to HACs a few years ago, and many private insurers are now following suit.

New Opportunity in Infection Fight

By Dr. P.J. Brennan and Dr. Neil Fishman Posted: May 23, 2011 – 12:01 am ET

The Obama administration’s Partnership for Patients: Better Care, Lower Costs, announced last month, sets a bold agenda for improving the U.S. healthcare system and shines a spotlight on an issue that has been a central focus of epidemiologists for many years: the reduction of preventable healthcare-acquired infections. Specifically, the partnership seeks to reduce hospital-acquired conditions by 40% by 2013.The Society for Healthcare Epidemiologists of America has long been a proponent of working toward the elimination of HAIs, and the launch of this partnership represents an opportunity for healthcare workers at every level, healthcare institutions and patients alike to join in this effort. The costs associated with not addressing HAIs and their causes are dire.With estimates as high as 2 million Americans contracting an infection during hospitalization and nearly 100,000 dying annually, the elimination of HAIs should be one of our highest national health priorities. Headline-making HAIs caused by resistant germs such as methicillin-resistant staphylococcus aureus and clostridium difficile, along with many others as serious, are extremely difficult to treat and can be deadly. The overuse and misuse of antibiotics are the root causes of highly resistant organisms and by failing to address this problem, we leave ourselves and our patients vulnerable to disease, death, higher healthcare costs and at the mercy of fewer treatment options. Increasing drug resistance and the failure of society to keep pace with antibiotic development pose the threat of a return to the pre-antibiotic era of the past century.
Now that the Obama administration has focused the attention of those of us working within the healthcare system, as well as the public, on improving patient safety in a collaborative and coordinated way, how exactly do we go about doing so, and what specifically should we focus on in order to achieve results? The answers lie in applying what we know now and in learning more about the problems we face.

First, we must adhere to proven practices for infection prevention. Hand hygiene, isolation precautions and the guidelines promulgated by SHEA, the Centers for Disease Control and Prevention and other professional societies serve as the foundation of our current efforts. However, these tools are necessary but insufficient in our current battle against HAIs. We must invest in the medical research and technology that will enable us to identify how our healthcare system can avoid the errors leading to HAIs.

Unfortunately, despite the fact that HAIs are among the top 10 causes of death in the U.S., our scientific knowledge base is riddled with significant gaps. We are in desperate need of deeper levels of understanding regarding the epidemiology, pathogenesis and prevention of these infections. The only way to address these gaps is through broad and multifaceted research. The launch of the Partnership for Patients, along with recent public and legislative interest in reducing rates of HAIs, are signs of an encouraging momentum needed to address and answer important research questions about these infections. Current levels of research funding for HAIs will be inadequate to advance the cause of elimination. Only $18 million in National Institutes of Health funding is directed to HAI prevention. In contrast, more than $2 billion is awarded annually for the investigation of other worthy conditions such as cardiovascular disease and HIV.

Finally, we must enhance our surveillance networks, a critical factor in the detection and control of infectious diseases. A prime example of the need for such a mechanism is a recent study of an extremely antibiotic-resistant bacterium known as carbapenem-resistant Klebsiella pneumoniae in Los Angeles. Last spring, the L.A. County Department of Public Health voluntarily chose to monitor for this bacterium in its hospitals and nursing homes, despite the widely held belief that the infection was limited to the East Coast. Through the use of mandatory lab reporting of CRKP when found during testing, county officials discovered startlingly high rates of the germ, particularly in long-term acute-care hospitals. L.A. County health officials are to be commended not only for monitoring and reporting the presence of CRKP, but for providing such a lucid example of the critical importance of such action. Had a national surveillance network to identify such infections been in place, CRKP may have been kept in check when it was first discovered in the New York-New Jersey area almost 10 years ago.

Partnership for Patients is a commendable effort that is encouraging to those of us in the field of epidemiology who are dedicated to working toward the elimination of HAIs. Achieving that goal will require the collaboration of health professionals, patient engagement and dedication of resources that are described in the plan. Every healthcare professional would rather be in the position of preventing than treating an infection; this couldn’t be truer than in the case of HAIs. One of the things that epidemiology has taught us is that implementing changes and improvements to the healthcare system without understanding and advancing the science behind those changes would have dire consequences. Not only would we fall short of the worthy goals of improving patient safety, ensuring high-quality care and reducing medical costs, but we would leave ourselves poorly equipped to face the emerging threats that lie ahead.

Dr. P.J. Brennan is chief medical officer of the University of Pennsylvania Health System, Philadelphia. Dr. Neil Fishman is associated chief medical officer of the system. Both are past presidents of the Society for Healthcare Epidemiology of America.

Adverse Events May be 10 times Higher Than Reported

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured…Author Affiliations
David C. Classen (dclassen@csc.com) is an associate professor of medicine at the University of Utah, in Salt Lake City.
Roger Resar is a senior fellow at the Institute for Healthcare Improvement, in Cambridge, Massachusetts.
Frances Griffin is a faculty member at the Institute for Healthcare Improvement.
Frank Federico is an executive director at the Institute for Healthcare Improvement.
Terri Frankel is a director at the Institute for Healthcare Improvement.
Nancy Kimmel is director of quality and safety at the Missouri Baptist Medical Center, in St. Louis.
John C. Whittington is a senior fellow at the Institute for Healthcare Improvement.
Allan Frankel is an associate professor at Brigham and Women’s Hospital, in Boston, Massachusetts.
Andrew Seger is an assistant professor at Brigham and Women’s Hospital.
Brent C. James is chief quality officer at Intermountain Healthcare, in Salt Lake City, Utah.

Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals.

We found that the adverse event detection methods commonly used to track patient safety in the United States today—voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators—fared very poorly compared to other methods and missed 90 percent of the adverse events.

The Institute for Healthcare Improvement’s Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.

Psychology Theory Can Improve Hand Hygiene

May 26, 2011 (Dallas, Texas) — Feedback based on psychological theories improves hand hygiene compliance among healthcare workers, according to a study presented here at the Society for Healthcare Epidemiology of America 20th Annual Scientific Meeting.Research has shown that feedback helps healthcare workers follow guidelines, and that hand hygiene interventions must be repeated regularly to be effective. Most existing studies of hand hygiene interventions involve small samples and short time periods, and few use psychological theories in the design of interventions.The researchers conducted a 3-year randomized controlled trial of a feedback intervention designed from psychological theory. The study took place between October 2006 and December 2009 at 60 wards — 16 intensive treatment units (ITUs) and 44 acute care of the elderly (ACE) wards — in 16 English and Welsh hospitals.The intervention consisted of a repeated 4-week cycle (20 to 30 min/week) of observation, feedback, and action planning with healthcare workers and groups, which were recorded on forms. Of the 60 wards, 33 (11 ITU, 22 ACE) were randomized to receive intervention. An intention-to-treat analysis revealed an increase in the odds ratio (OR) for hand hygiene compliance in ITUs (1.44; 95% confidence interval [CI], 1.18 to 1.76; P < .001), but not in ACE wards.A per-protocol analysis showed an increase in OR for compliance for ACE wards (OR, 1.67; 95% CI, 1.28 to 2.22; P < .001) and ITUs (OR, 2.09; 95% CI, 1.55 to 2.81; P < .001). Among non-implementing wards, OR decreased for ACE wards and remained the same for ITUs. In ITUs, the degree to which the intervention was followed tracked with compliance (OR for compliance, 1.12; 95% CI, 1.04 to 1.20; P = .003 per completed form).
“This study provides the strongest evidence yet that this is an effective technique when coupled with the repeated cycle of personalized goal-setting and action planning. Although a further implementation study is clearly required, infection control staff could consider employing this intervention with the same cycle and behavioral principles to supplement their current audit systems,” Sheldon Stone, MD, FRCP, director of the stroke unit at the Royal Free Campus, University College London Medical School, United Kingdom, said during his presentation of the research.

The study lends more credence to the long-held belief that psychology-based feedback could improve hand hygiene compliance.

“They were able to increase compliance over a long period of time. I think it’s a very exciting result. It confirms something we thought we knew, but it uses rigorous science to do that,” Arjun Srinivasan, MD, associate director for healthcare-associated infection prevention programs at the Centers for Disease Control and Prevention in Atlanta, Georgia, told Medscape Medical News.

Dr. Srinivasan believes the results could be transferable to other institutions. “The study wasn’t just in one large hospital, and they had a large diversity of healthcare centers. They really did work in a real-world setting.”

The study did not receive commercial support. Dr. Stone and Dr. Srinivasan have disclosed no relevant financial relationships.

Mandatory Reporting of Medical Errors

Mandatory Reporting of Medical Errors: Crafting Policy and Integrating it into Practice

Abstract and Introduction
Estimations of preventable adverse events as a result of medical errors range from at least 44,000 to as many as 98,000 American deaths annually. Further, according to the National Practitioner Data Bank’s 2006 Annual Report, 12.2% of medical malpractice payments against nurse practitioners (NPs) were a consequence of medication-related problems. Implementing mandatory reporting of all medical errors and “near misses” (errors that produce minimal or no patient harm) may be one policy approach to this problem.

In 1995, Kingdon began to consider how an issue is placed on a political agenda and eventually translated into a public policy. As Kingdon noted, under certain circumstances, a window of opportunity is created, and given current changes in both the executive and legislative branches of the federal government, there may now be the perfect opportunity to address medical errors and near misses. This serious public health issue is analyzed using Kingdon’s model, and policy approaches aimed at diminishing medical errors are considered.IntroductionThe United States has the most expensive health care system in the world.

In 2006, the United States spent approximately $5711 per person for health care. Luxembourg was ranked second, with expenditures of about $4611 per person. The United Kingdom, which is characterized by a nationalized health system that provides care to all citizens, spent $2317 per person (40.57% of the amount spent per capita in the United States).[1] Despite the relatively high sums of money that are spent to meet the health care needs of U.S. citizens, the overall quality of health care provision in the United States remains troublesome, because one of the top 10 leading causes of deaths per year are health care-related mistakes.[2] Estimations of preventable adverse events due to medical errors range from at least 44,000 to as many as 98,000 American deaths annually.[2] According to the National Practitioner Data Bank’s 2006 Annual Report, 12.2% of medical malpractice payments against nurse practitioners (NPs) resulted as a consequence of medication-related problems.[3] Implementing mandatory reporting of all medical errors and “near misses” (where harm would have resulted absent immediate recognition of an error and just-in-time intervention) in the United States may be one policy approach to this problem.

Mandatory reporting of medical errors is part of a system that holds providers accountable for serious patient injuries and deaths. Most mandatory reporting systems are operated by state regulatory programs that have the authority to investigate facts surrounding specific cases and issue penalties or fines for provider or facility wrong-doing.[4] Each state has the responsibility for delineating the specific types of adverse outcomes that must be reported and in what fashion.

In Maryland, for example, the Maryland Department of Health and Mental Hygiene administers a mandatory patient safety reporting system for specific adverse patient-related events. The following events must be reported within 5 days: falls, treatment delays, airway management errors, medication errors, complications, death/disability associated with the use of a vascular device, unanticipated intraoperative or immediate postoperative death, misdiagnosis, post surgical retention of a foreign body, suicide or attempted suicide, maternal or fetal injury or death, malfunctioning devices, intravascular air embolism, hypoglycemic event, staff member failure to act, restraint-related death, blood transfusion reaction, anticoagulation, and surgical procedure not consistent with consent.[5] While mandatory adverse event reporting is growing in frequency within the United States, it does not tell the complete story in terms of health care adverse events. This is partially due to the fact that mandatory reportable events are considered by safety experts to be the “tip of the iceberg,” or a small subset of errors indicative of care delivery breakdown that can lead to patient injury.[2]

Kingdon’s Multiple Streams Framework (2003): A Model for Analysis of Mandatory Reporting of Preventable Medical Errors and Near Misses

In 1995, Kingdon began to consider how an issue is placed on a political agenda and is eventually translated into a public policy. As Kingdon noted, under certain circumstances, a window of opportunity is created and, “a problem is recognized, a solution is available, the political climate makes the time right for change, and the constraints do not prohibit action.[6] [p.96] Kingdon designated 3 “streams” that created such a window of opportunity during which policy makers are willing to seriously consider legislation aimed at improving a situation or solving a problem.[6]

The first stream, termed the problem stream, consists of indicators that support the existence of a problem. Problem streams may comprise research that establishes there is a problem. Or, a well-publicized occurrence may bring the issue to the attention of policymakers. The second stream, designated the policy stream, relates to input from specialists in the area under consideration. For instance, in terms of medical error reporting, health care groups, patient groups, and health care providers are all contributors to information grouped in the policy stream. The final stream, the political stream, considers political input into the matter. The political stream typically looks at national “mood” surrounding the identified issue, changes in administration, and political opponents and proponents of an issue.[7,8]

The Problem Stream and Preventable Medical Errors

Deaths attributable to medical mistakes are thought to exceed the number of fatalities caused by motor vehicle collisions (45,316); breast cancer (41,210); and AIDS (12,113).[2,9] Despite the fact that these figures have been disputed as an overestimation,[10] they provide a strong impetus to consider regulations and laws aimed at reducing medically-induced morbidity and mortality.

One recent example of a preventable medical error has entered the problem stream. Within the past year, the newborn twins of Kimberly and Dennis Quaid, a well-known actor, were inadvertently administered potentially lethal amounts of heparin. Indeed, these infants had received a dose of heparin that was 1000 times stronger than the prescribed amount, and the issue of preventable medical error was raised across the country.[11] Such a case illustrates the need for laws (and accompanying regulations) aimed at reducing the occurrence of such potentially fatal errors. Utilization of bar coding on medication vials that notes the drug name and drug strength may be one strategy that could be mandated by state or federal regulations to reduce these types of errors. Additionally, patient ID bracelets that are coded to correlate the patient with the proper medication are another method that has been suggested to avoid these types of incidents.

Research from experts in the area of health care and health policy further support the need for additional laws related to mandatory reporting of preventable medical errors and near misses. A recent study conducted by Health Grades, a health care advocacy group, provides useful information on patient safety.[12] The research findings of this study concluded that patient safety mishaps cost the federal Medicare program 8.8 billion dollars and led to 238,337 potentially preventable deaths during the 2004 to 2006 timeframe. More specifically, this analysis of 41 million Medicare records from 5000 non-federal hospitals, found that patients had a 1 in 5 chance of dying as a result of a medical error during the study period.[13]

In the book To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) proposed implementation of voluntary and mandatory reporting of adverse patient events in hopes it will lead to strategies to reduce their occurrence. Recognizing a need to further analyze the public health issues surrounding medical errors, the IOM called for a change in policy to establish nationwide voluntary and mandatory reporting systems. The purpose of the policy change was twofold: voluntary reporting of errors that produce minimal or no patient harm (termed near misses) and mandatory reporting of errors that lead to serious patient harm or death (termed preventable adverse errors). The goals of this policy are to improve the overall quality of health care delivery in 3 ways. First, they provide the public with a degree of protection by requiring that the most serious errors are reported, investigated, and appropriately managed. Secondly, they provide an incentive for health care organizations to improve quality of care to avoid public exposure and potential penalties. And finally, they require all health care organizations to make a dedicated commitment to ongoing patient safety practices.[2]

As a consequence of this IOM policy, as of 2007, 25 states and the District of Columbia had implemented a mandatory adverse reporting system and only one state had adopted a voluntary system that met the National Academy for State Health Policy (NAHSP) criteria for adverse events reporting.[3] Between 2005 and 2007, 15 states and the District of Columbia enacted or revised patient safety reporting systems through legislative and or regulatory activity. According to the NAHSP, more states are demonstrating growing interest in incorporating adverse events reporting to promote quality improvement as they analyze root causes, collect information about near misses, and develop web-based systems.[3]

Unfortunately, the process of legislating mandatory medical error reporting via state legislation has been slow. Some policy advocates believe that stronger federal reporting requirements will be needed if true change is to be effectuated. Some of the most outspoken interest groups and organizations lobbying on this patient safety issue include public citizen groups, the Association of Trial Lawyers of America, the American Medical Association, the American Hospital Association (AHA), the American Nurses Association (ANA), the Blue Cross and Blue Shield Association, and the Joint Commission.[13]

Additional stakeholders in this issue include NPs, physicians, nurses, pharmacists, and any other providers of health care who have become more aware of patient safety issues and who are committed to improving the quality of care given.[14] Voluntary reporting of medical errors is another potential way to guide the direction of internal quality improvement programs because these events typically include errors that resulted in little to no harm to the patient. Studying these types of errors can help identify and correct care delivery systems before serious harm to the patient occurs. Mandatory and voluntary reporting of adverse events is totally reliant on the honesty of the provider in disclosing the occurrence of an adverse event. Unfortunately, self-reporting of medical-related errors has not been a consistent strength of health care providers, and there are some providers who should not be delivering care because they engage in unsafe behaviors. This is due to the fact that some providers do not want to face their peers, they fear lawsuits, and they worry about the stigma associated with being the cause of an adverse patient outcome. Furthermore, there are few incentives for providers to report mistakes.[15]

A recent survey of 1082 U.S. physicians elicited attitudes on strategies to improve patient safety and found that only 30% of the respondents thought the current systems for hospitals or health care facilities were acceptable. When asked what would make them more likely to fully participate with a medical errors self-reporting system, they replied that reports would need to be kept confidential and nondiscoverable (88%), the information would need to be used solely for delivery system improvements (85%), reporting would need to be nonpunative (84%), and that the error reporting process would need to take less than 2 minutes (66%). The respondents also contended that such information would have to be kept at the local unit or department where the event occurred (53%).[16]

Milch et al analyzed 92,547 medical error and adverse events that were voluntarily reported by 26 acute care hospitals.[17] The electronic reporting system consisted of a secure, intranet web-based system available on all hospital computers. The reported errors occurred during 2,547,154 patient days at the hospitals under study. The rates of reporting varied widely between the hospitals in question, with rates of 9 to 95 reports per 1000 inpatient days. There was also a great disparity in the type of provider that reported the errors, with nearly half of the entries made by registered nurses, but less than 2% filed by physicians.[17]

Another large analysis of some 266,224 adverse events that were reported over 7.3 million inpatient days concluded that physicians reported 1.1% of the total medical error events, nurses 45.3%, and other hospital employees 53.6%. Physicians were more likely to report events that led to permanent harm, near death, or death of a patient (P < 0.01). Nurses were more apt to report events that caused no harm or temporary injury (P < 0.01). However, nurses were more likely to report events across all levels of severity, as opposed to the narrower spectrum of events that physicians reported.[18]

One of the most frequently cited barriers to effectively implementing a voluntary medical error reporting system is fear that individual providers and health care facilities will be subject to legal reprisal.[13,14,19] Health care quality and safety experts have noted that “any effort to prevent injury due to medical error is complicated by the dead weight of a litigation system that induces secrecy and silence.”[15] [p.1124] Brennan stresses the importance of malpractice reform to encourage providers to openly discuss iatrogenic patient injuries without fear of reprisal in the form of malpractice litigation. And, until the policies are changed regarding tort reform to permit confidential medical error reporting, without a fear of reprisal, there will be little change in the current systems of adverse event reporting.[15]

Not surprisingly, additional concerns center on fear of increased malpractice insurance rates; adverse harm to professional reputation; loss of personal confidence; and increased anxiety regarding making future errors to the point of significant post error-related stress response.[19] Successful voluntary and mandatory programs for reporting adverse events are thought to share 3 basic components. Namely, the provider reporting to these programs feels safe from reprisal, is not blamed or rebuked, and the reporting of the event is possible on a 1-page form. Much of the experience and success with this type of system has been refined and proven with programs like the Aviation Safety Reporting System. This system designates important potential areas for aviation risk reduction (pilot training, communication mechanisms, mechanical issues, air traffic control, and the like) and monitors these areas. Based on this monitoring system, risk reduction techniques are suggested and implemented.[21]

The Political Stream and Preventable Medical Errors

The political stream analyzes the national “mood” related to an issue. Congressional action concerning medical errors appears to indicate that there is some political interest in reducing medical errors. In 2001, Congress allocated $50 million annually to the Agency for Healthcare Research and Quality (AHRQ), the lead government agency for United States health care safety. The Veteran’s Health Administration, the Joint Commission, the Centers for Medicare and Medicaid Services, as well as major health care organizations and payers, have all advocated for policy change to deal with the quality of health care in the United States.

The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), signed into law on July 29, 2005, was enacted in response to growing concern about patient safety in the United States, IOM’s report, and AHRQ data.[22] The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients. The Act also creates Patient Safety Organizations (PSO) to collect, aggregate, and analyze health care provider-reported confidential information. It is hoped that these PSOs will be able identify patterns of adverse events to enable development of measures to eliminate patient safety risks. A final requirement of the Act is to promote the establishment of a Network of Patient Safety Databases (NPSD) to serve as an evidenced-based interactive resource center for health care providers. The Department of Health and Human Services provides ongoing technical support to the PSOs.

The main policy argument in favor of reporting adverse events is that it builds greatly upon a health care reform plan proposed by President Obama in 2008. The proposed plan seeks to modernize the system and provide affordable and portable health care coverage to all Americans at lower cost and higher levels of quality. This plan would actively fund improvements in health information technology aimed at reducing unnecessary spending that results from inefficient paper billing systems and preventable errors.[23]

This policy is in keeping with opinions expressed by President Obama and Secretary of State Clinton that stated: “To improve both patient safety and the medical liability climate, the tort system must achieve four goals: reduce the rates of preventable patient injuries, promote open communication between physicians and patients, ensure patients access to fair compensation for legitimate medical injuries, and reduce liability insurance premiums for health care providers. Addressing just one of these issues is not sufficient.”[24] [p.2205]

Converging of the Streams: The Time is Right for Mandatory Reporting of Medical Errors and Near Misses

Given the current public, provider, and legislative focus on medical errors, it appears there is a window of opportunity to better address the issue of medical errors. One option would be to continue on the current path and await state requirements for such options. However, given the relatively slow speed of state regulations, this does not appear to be an ideal approach. A second option would be to tie federal funding of state health activities to mandatory state legislation. However, this would exacerbate tensions between state and federal health agencies and may not be a preferable solution. The third, and likely the most comprehensive approach, would be to enact federal legislation requiring mandatory reporting of medical errors and near misses. One factor that must be considered is the federal deficit and the costs that would be associated with the establishment and maintenance of such a federal system. It is true that the system would necessitate the need for federal expenditures during a time of economic instability in the United States. However, it is likely that such costs would be greatly offset by the price tag associated with even a handful of preventable medical errors. Further, self-reporting of potential and actual errors could be incentivized by ensuring that such reports would not be discoverable in a court of law, fostering anonymous reporting systems, and providing funding for research projects that analyze reported data and generate appropriate responses to improve patient safety. It is hoped that NPs and other providers who are concerned with preventable medical errors and near misses will act while the environment is so favorable.

References

1. Kaiser Family Foundation. Health spending in the United States and OECD countries. Available at: http://www.kff.org/insurance/snapshot/chcm010307oth.cfm January 2007; Accessed June 11, 2009.

2. Institute of Medicine. To err is human. Washington, DC: National Academy Press; 2000.

3. U.S. Department of Health and Human Services. National practitioner data bank. Available at: http://www.npdb-hipdb.hrsa.gov/annualrpt.html Accessed May 25, 2009.

4. Rosenthal J, Takach M. 2007 Guide to state adverse event reporting systems. State Health Policy Sur Rep. 2007;1:1–10.

5. Code of Maryland Regulations 10.07.06: hospital adverse event reporting. Available at: www.hashp.org, www.pstoolbox.org Accessed May 25, 2009.

6. Kingdon JW. Agendas, alternatives, and public policies. 1st ed. New York: Harper Collins College Publishers; 1995.

7. Odom-Forren J, Hahn EJ. Mandatory reporting of health care-associated infections: Kingdon’s multiple streams approach. Policy Polit Nurs Pract. 2006;7:64–71.

8. Milstead JA. Health policy and politics: a nurse’s guide. 3rd ed. Boston: Jones & Bartlett; 2008.

9. Centers for Disease Control and Prevention National Center for Health Statistics. Births and Deaths: final data for 2006. Natl Vital Stat Rep. 2009;57:1–80.

10. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286:415–420.

11. Cable News Network. Dennis Quaid’s twins get accidental overdose. Available at: http://www.cnn.com/2007/SHOWBIZ/Movies/11/21/quaid.newborns.ap/index.html Accessed December 3, 2008.

12. HealthGrades. Medical errors cost U.S. $8.8 billion, result in 238,337 potentially preventable deaths, study shows. Available at: http://www.sciencedail.com/releases/2008/04/080408085458.htm Accessed December 1, 2008.

13. Mattie AS, Ben-Chitrit R. Patient safety legislation: a look at health policy development. Policy Polit Nurs Pract. 2007;8:251–261.

14. Leape LL, Berwick DM. Five years after to err is human: what have we learned?. JAMA. 2005;293:2384–2390.

15. Brennan TA. The Institute of Medicine Report on Medical Errors: could it do harm?. New Engl J Med. 2000;342:1123–1125.

16. Garbutt J, Waterman AD, Kapp JM, et al. Lost opportunities: how physicians communicate about medical errors. Health Aff. 2008;27:246–255.

17. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events an analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. 2005;21:165–170.

18. Rowin EJ, Lucier D, Pauker SG, et al. Does error and adverse event reporting by physicians and nurses differ?. Jt Comm J Qual Patient Saf. 2008;34:537–545.

19. Cooper JB. Is voluntary reporting of critical events effective for quality assurance?. Anesthesiology. 1996;85:961–964.

20. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors in practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467-476.

21. Leape LL. Reporting of adverse events. New Engl J Med. 2002;347:1633–1638.

22. Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41). Signed into law on July 29, 2005. Available at: http://www.pso.ahrq.gov/statute/pl109-41.htm Accessed November 5, 2008.

23. Obama’s Health Policy Agenda. Available at: http://healthpolicyandmarket.blogspot.com/2008/03/detailed-analysis-of-barack-obamas.html Accessed December 7, 2008.

24. Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. New Engl J Med. 2006;354:2205–2208.

Self-reported Medical, Medication and LaboratorySelf-reported Medical, Medication and Laboratory Error in Eight Countries

Self-reported Medical, Medication and Laboratory Error in Eight Countries Posted: 04/08/2011;International Journal for Quality in Health
Care. 2011;23(2):182-186. © 2011 Oxford University Press

Abstract and Introduction

Abstract

Objective.To identify risk factors associated with self-reported medical, medication and laboratory error in eight countries.

Design. The Commonwealth Fund”s 2008 International

Health Policy Survey of chronically ill patients in eight countries.

Intervention. None.

Setting and Participants. A multi-country telephone survey was conducted between 3 March and 30 May 2008 with patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA who self-reported being chronically ill.

Main Outcome Measure. A bivariate analysis was performed to determine significant explanatory variables of medical, medication and laboratory error (P < 0.01) for inclusion in a binary logistic regression model.

Results. The final regression model included eight risk factors for self-reported error: age 65 and under, education level of some college or less, presence of two or more chronic conditions, high prescription drug use (four+drugs), four or more doctors seen within 2 years, a care coordination problem, poor doctor–patient communication and use of an emergency department.

Conclusion. Risk factors with the greatest ability to predict experiencing an error encompassed issues with coordination of care and provider knowledge of a patient”s medical history. The identification of these risk factors could help policymakers and organizations to proactively reduce the likelihood of error through greater examination of system- and organization-level practices.

Background

Patient safety has become a growing international health policy initiative as evidenced by the
World Health Organization”s World Alliance for Patient Safety. With the knowledge that medical and medication errors are responsible for numerous injuries and deaths every year, international campaigns have set out to reduce medical errors by improving continuity of care, assuring medication accuracy and improving communication.[1]

Research from North America has echoed mounting international evidence for patient safety strategies aimed at reducing or mitigating errors. The Canadian Adverse Events Study found a 7.5% incidence rate for adverse events during hospitalization, extrapolating to roughly 185 000 hospital adverse events annually.[2] Furthermore, 70 000 of these adverse events found to be potentially preventable. The Harvard Medical Practice Study conducted in 1984 and the Institute of Medicine”s To Err Is Human published in 1999 concluded that at least 44 000, and as many as 98 000 people, die in hospitals each year as a result of preventable medical errors in the USA.[3, 4] The economic burden of medical errors has also been explored, with results indicating that additional medical expenses and hospitalizations, as well as disability and litigations, cost some countries billions of dollars every year.[4, 5]

The magnitude of complications associated with medical and medication errors warrants the identification of risk factors of these events, thereby allowing for policy directives and patient education materials aimed at reducing or mitigating risks. Examining which factors present the highest risk for experiencing and error, and better targeting at-risk patients, may help to increase patient safety at both the system and individual levels. Furthermore, identifying common risk factors present across several countries may better help to influence health policy reform and direct international and domestic campaigns.

As such, the objective of this study was to identify common risk factors associated with self-reported medical, medication and laboratory errors in eight countries.

Methods

The Commonwealth Fund”s 2008 International Health Policy Survey of chronically ill patients, conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA, was the primary data source for this research. In each country, surveys were conducted with adults 18 years of age and older who were considered to have chronic and ongoing health needs. Eligible adults self-reported at least one of the following criteria:

  • (i) fair or poor health condition,
  • (ii) a serious or chronic illness, injury or disability that has required a lot of medical care in the past 2 years,
  • (iii) hospitalization (for something other than uncomplicated delivery of a baby) in the past 2 years or
  • (iv) major surgery in the past 2 years.

Surveys were conducted by telephone in all eight countries by Harris Interactive, Inc. The average length for the survey was 17 min for eligible respondents, ranging from an average of 14–22 min across countries. Data were weighted according to the most recent census information in each country to reflect demographic distributions. Complete survey methods, along with average rates of errors and other results, have been reported previously.[6] We received permission from the Commonwealth Fund to use the raw survey data for the purpose of this paper.

Bivariate analysis was used to determine eligible variables for inclusion in a logistic regression
model. The dependent variable of interest was whether the respondent had experienced a medication error, medical mistake or diagnostic test error within the past 2 years (collectively referred to as “error”). Explanatory variables were chosen based on known and hypothesized risk factors for an increased likelihood of experiencing an error. Variables included in the bivariate analysis represented key demographic indicators, patient health indicators, use of emergency health care and patient–provider relationship indicators, including age, sex, education level, presence of chronic conditions, prescription drug use, number of doctors seen, poor provider communication, poor care coordination and emergency department (ED) use. A χ 2 test of significance at α = 0.01 was used. Comparisons were made between respondents who indicated they had experienced an error within the past 2 years and those who did not. Only explanatory variables that satisfied the χ 2 test of significance (P < 0.01) were then included in the logistic regression model.

Binary logistic regression was used due to the presence of a binary dependent variable (either
experiencing an error in the past 2 years or not). Significant variables
identified through the bivariate analysis were then included within the binary
logistic regression model to determine their ability to predict experiencing an
error. The logistic coefficient, standard error, χ 2 probability were calculated. In addition,
the odds ratio (OR) for each explanatory variable was calculated to determine
the relative risk of experiencing an error given each hypothesized risk factor.
Goodness-of-fit was determined using the Hosmer and Lemeshow test, and
multicollinearity was determined through an analysis of explanatory variable
correlations. Data analysis was performed using PASW Statistics version 18.0.[7]

Results

The final data set included a total of 9944 adults aged 18 and older in eight countries.

Demographic characteristics are listed in Table 1.

Study on Hospital-Acquired Infections (HAI)

Study on Hospital-Acquired Infections (HAI) Flags Central Florida Facilities

Several Central Florida hospitals were among the worst in the state for life-threatening infections and conditions related to patient stays, according to recently released data from the federal government. Many had rates for falls, blood infections, even bedsores that were several times the national average.Orlando Health, for instance, had the highest rate of life-threatening blood infections in the state of Florida: four times the national average.South Lake Hospital’s rate of falls among seniors was almost three times the national average, as was Bert Fish Medical Center’s in Volusia County.In Daytona Beach, Florida Hospital Memorial Medical Center had a rate nearly seven times higher than the national average for foreign objects left in patients. And Leesburg Regional’s rate in that category was about five times the national average.

In the category of bedsores, Winter Haven Hospital had the second-worst rate in the state and was five times higher than the national average.

The federal government released the data based on how often Medicare patients left hospitals with infections or other problems related to their stays. The eight conditions included were blood infections from catheters; urinary-tract infections from catheters; falls; serious bedsores; blood transfusions with incompatible blood; complications from air or gas bubbles entering a blood vessel; poor control of blood sugar for diabetics; and foreign objects left in a patient during surgery.

These conditions were selected because they are “reasonably preventable,” said Shaheen Halim, director of the Centers for Medicare and Medicaid Services’ division of hospitals and medication measurement. Medicare stopped paying hospitals for treatment of these conditions in 2008.

Publishing them, she said, would give patients a view into how their local hospitals operate.

“These [statistics] measure outcomes that a patient might want to know about before choosing a hospital. They might want to see how many of these events occurred at a particular facility,” Halim said.

To gather the information, the Centers for Medicare and Medicaid Services used billing information from hospitals that treated traditional Medicare patients (those in a fee-for-service Medicare, not Medicare Advantage) from October 2008 to June 2010.

The most common condition reported was injury from a fall or some other type of trauma. More than 70 percent of hospitals reported at least one fall or trauma during the 18-month period.

Rates for infection also were common, with about 45 percent of hospitals reporting at least one blood or urinary-tract infection developed during the hospital stay. Rates were lowest for instances of blood incompatibility, which occurred once in every 1 million discharges, CMS said.

Contesting the data

Officials at Orlando Health contested the data and on May 27 sent their complaints to Medicare administrators.

Because Orlando Health’s five hospitals include the area’s only Level One trauma center, hospital officials say their system receives more traumatic — and complicated — cases than other local hospitals. Those cases are more likely to require catheters and lengthy hospital stays, hospital officials said.

In addition, Orlando Health officials complained that Medicare based its figures on billing codes, which staff can enter incorrectly — for example, mistaking inflammatory cellulitis for the more serious infectious cellulitis.

That, said spokeswoman Kena Lewis, may have led to Orlando Health appearing to have a higher rate of blood infections than was the case.

“We’re sending our comments and concerns about the methodology to CMS,” Lewis said, adding that she didn’t know whether to expect a response from the agency.

Not far behind Orlando Health for life-threatening blood infections were Shands Hospital at the University of Florida, Lakeland Regional Medical Center, Bert Fish Medical Center in New Smyrna Beach and Osceola Regional Medical Center — all of which had rates of blood infections well above the national average.

These vascular catheter-induced infections — known to most surgeons as “central line infections” — result after tubes are placed in a large vein in a patient’s neck, chest or arm and an infection occurs.

At Florida Hospital Memorial Medical Center, where the issue was foreign objects left in patients, officials disputed the findings, saying that using electronic reports to compile the data may have skewed the results.

“For example, the intentional insertion of a surgical item — such as a surgical staple to prevent internal bleeding — could be erroneously captured as leaving a surgical object behind,” said hospital spokeswoman Lindsay Rew.

At South Lake Hospital, where the rate of falls among seniors was almost triple the national average, spokeswoman Kimberly Couch said the hospital began trying to improve patient safety before the Medicare study was completed.

The hospital now conducts hourly rounds to patients’ rooms to monitor their activity and needs. That, Couch said, should reduce the risk of a patient getting up for something and falling. In addition, staffers, patients and family members are being educated about the risk of falling and how to prevent falls.

“It is always a challenge with falls to monitor patient activity while allowing for as much independent activity as possible,” Couch said. “We are confident that these initiatives will lead to improved patient safety.”

Other hospitals, including Osceola Regional and Bert Fish Medical Center, did not return requests for comment.

Where they stand

Publishing this information helps consumers and hospital officials, said Dr. David Goodman, director of the Center for Health Policy Research at Dartmouth Medical School.

“Hospitals don’t know how they stand until they receive this type of data,” Goodman said. “This helps them decide where to concentrate their efforts.”

The Institute of Medicine — an independent, nonprofit organization without ties to the government — estimates that as many as 98,000 Americans die in hospitals each year from preventable medical errors.

Patient advocates, including some doctors, applauded Medicare’s move, saying the release of the information will push hospitals to perform better.

“Public reporting is an important way of stimulating the improvement of care,” Goodman said. “The health-care profession has often looked at quality as a private matter, partly to avoid legal liability, so it has kept quality activities under wraps with the idea that health-care professionals can really measure quality and work on it without the fear of being sued.

“On the other hand, quality indicators are of obvious importance to patients,” he said. “It is information about them, and it is information that is related to their chances of getting better or worse care.”

What matters most

For consumers, Medicare’s list of eight complications may seem daunting. What should consumers pay more attention to? That, says Dr. Clifford Ko of the American College of Surgeons, depends on why you’re going into the hospital.

“If you’re undergoing surgery, then retained foreign bodies are probably more important to you” than controlling blood sugar for patients with diabetes, Ko said. On the other hand, if you or your parent is frail and likely to fall, the information on falls at hospitals may be more relevant.

Taken all together, a hospital’s scores tell consumers “how a hospital is doing,” Ko said. And he says that consumers will soon begin seeing more of this type of information from the federal government.

“I do think our health-care system is going to increase the number of metrics out there, so it will be easier for patients to get a picture of what the hospital does well,” Ko said.

Federal officials say they plan to update the data on these eight complications once a year. By doing so, hospitals can chart their progress, and consumers can stay up-to-date on how their local hospitals are performing, Halim said.

lshrieves@tribune.com or 407-420-5433

The 8 conditions

The Centers for Medicare and Medicaid Services released the data recently, posting them on its Hospital Compare website, so consumers can see how often patients leave their local hospitals with particular “hospital-acquired conditions.”

The eight conditions are:

  • •Blood infections from a catheter placed in the hospital.
  • •Urinary-tract infections from a catheter placed in the hospital.
  • •Falls, burns, electric shock, broken bones and other injuries during a hospital stay.
  • •Blood transfusions with incompatible blood.
  • •Bedsores that develop after a patient enters the hospital.
  • •Complications from air or gas bubbles entering a blood vessel.
  • •Objects left in patients after surgery (such as sponges or surgical instruments).
  • •Poor control of blood sugar for patients with diabetes.

How Electronic Surveillance Systems Help…

How Electronic Surveillance Systems Help with CMS-Mandated CDC NHSN Surgical Reporting

The Jan. 1, 2012, NHSN reporting deadline for surgical site infections (SSI) is rapidly approaching, and many infection preventionists and hospital executives are asking whether electronic surveillance systems (ESS) can help meet the workload, quality and cost challenges inherent in the CMS reporting mandate.We discussed these challenges with Tracy Gustafson, MD, a CDC-trained epidemiologist, software architect and a director of medical affairs in BD Diagnostics’ Infection Prevention and Management unit.Q: What concerns Infection preventionists and administrators most about responding to the new CMS and NHSN reporting mandates?A: Beyond the obvious financial pressure to improve performance year-to-year to receive quality-related incentives and avoid penalties, infection preventionists are most concerned that data collection and reporting will divert their resources away from real prevention efforts. This is already a concern with bloodstream infection reporting required in 2011. Surgical procedure and SSI reporting requirements in 2012 will increase the reporting burden ten-fold.
Additional concerns relate to the unique challenges in reducing SSIs. Many steps and personnel are involved in pre-operative, perioperative and post-discharge care of surgical patients. These factors make identifying root causes and opportunities for surgical improvement difficult without a sophisticated surveillance system capable of extracting and mining process-related data.

Q: What makes SSI data collection and reporting so time-consuming?

Before reporting an SSI, the hospital has to report the denominator data. For example, to report a mediastinal infection after coronary artery bypass graft (CABG), at least 19 data elements must be reported on every patient who has a CABG. Then, numerator (infection) data must be collected on every patient who contracts a deep infection in this surgical site within 30 days of surgery. Hospital staff must collect surgical and infection data inside their facilities, and check with surgeons who are seeing patients post-discharge and track those outcomes as well.

Q: Why do infection preventionists need to be involved in collecting surgical data? For example, can non-clinical staff collect and report the data?

A: Identifying SSIs requires clinical judgment. For example, an infection preventionist evaluates signs and symptoms of infection, and uses rules provided by the CDC to help define whether an infection is an HAI. Collection and validation against NHSN rules can be automated to help identify possible infections for investigation, electronically document the infection and provide post-discharge follow-up capability.

Q: You mentioned “data validation.” Do ESS now diagnose healthcare-associated infections (HAI)?

A: No, quite the opposite. A viable ESS provides data that help the clinician determine when a HAI might be present, but the clinician must have the final say. Software can help by determining whether the data it receives are valid according to NHSN definitions and business rules. For example, in NHSN:

• Each surgical procedure has slightly different required data elements.

• Only specific sites of infection can follow each type of surgical procedure.

• Each site of infection must be documented by a specific combination of lab results, signs and symptoms.

• Data requirements also vary depending on the patient’s age.

Q: We’ve talked about surgical data. Does NHSN accept other kinds of data electronically?

A: NHSN has enabled electronic reporting of detailed device-day denominators, surgical procedure data, surgical site infections, central line-associated bloodstream infections (CLABSIs), urinary tract infections (UTIs), central line insertion practices (CLIP), and lab-identified MDRO/CDAD results.

Q: How can an ESS help reduce infections?

A: They can help by going beyond single event “alerts” to provide tools to study the epidemiology of infections in a given facility. Many ESS systems focus on providing alerts and line lists, but affecting change requires the ability to easily analyze processes and related outcomes.

Q: If I am an infection preventionist, how do I evaluate an ESS to see if it is right for me?

A: Focus on outcomes—what tools the system provides and how the tools will help you prevent infections. Ask for a list of alerts and reports produced by the system, how easy it is to create graphs and control charts inside the system, whether the system helps track processes as well as outcomes. Ask whether the system can benchmark to NHSN and produce graphs based on Standardized Infection Ratios, which NHSN plans to use to compare hospitals. Ask exactly which NHSN-required data elements can be transferred into coded fields for analysis. Ask whether you own your data at the end of a contract. If the answers to these questions are satisfactory, then you’ve probably found a system that benefits your patients, your healthcare staff and your bottom line.

Flu Tracking

Researchers Examine Seasonal Population Migration and Infection

Despite advances in surveillance and prevention, pneumonia and influenza (P&I) remain among the leading causes of mortality in the United States. Elderly adults experience the most severe morbidity from influenza-associated diseases, and have the highest rates of seasonal migration within the U.S. compared to other subpopulations. Kenneth K.H. Chui, of the Department of Public Health and Community Medicine at Tufts University School of Medicine in Boston, and colleagues, sought to assess spatiotemporal patterns in influenza-associated hospitalizations in the elderly, by time, geography, and intensity of P&I. Given the high seasonal migration of individuals to Florida, this state was examined more closely using harmonic regression to assess spatial and temporal patterns of P&I hospitalizations by state of residence.

Data containing all Medicare-eligible hospitalizations in the United States for 1991-2006 with P&I (ICD-9-CM codes 480-487) were abstracted for the 65-plus population. Hospitalizations were classified by state of residence, provider state, and date of admissions, specifically comparing those admitted between October and March to those admitted between April and September. The researchers then compared the hospitalization profile data of Florida residents with that of out-of-state residents by state of primary residence and time of year (in-season or out-of-season).

Chui, et al. observed distinct seasonal patterns of nonresident P&I hospitalizations, especially comparing typical winter destination states, such as California, Arizona, Texas and Florida, to other states. Although most other states generally experienced a higher proportion of non-resident P&I during the summer months (April through September), these states had higher nonresident P&I during the traditional peak influenza season (October through March).

According to the researchers, this study is among the first to quantify spatiotemporal P&I hospitalization patterns in the elderly, focusing on the change of patterns that are possibly due to seasonal population migration. Understanding migration and influenza-associated disease patterns in this vulnerable population is critical to prepare for and potentially prevent influenza outbreaks in this vulnerable population. Their research was published in BMC Public Health.

Hand Care Best Practice

Strategies to Boost Hand Hygiene Compliance
ICT asked invited clinical experts to discuss best-practice strategies that address hand hygiene compliance.

At the top of any qualified infection control agenda is the practice of proper hand hygiene. The Centers for Disease Control and Prevention (CDC) asserts that clean hands are the single most important factor in preventing the spread of dangerous healthcare-associated infections (HAIs) in healthcare settings. It is critical that infection control policies for hand hygiene are monitored for compliance regularly, as recent studies have illustrated a reduction in patient infection rates when hand hygiene protocols are correctly followed.

All hand hygiene policies should begin with the use of an alcohol-based rub before and after any resident contact, dealing with bodily fluids or any soiled materials, removing gloves and changing bedding or linens. This measure is imperative for preventing the spread of germs between residents via the medical staff. The CDC also recommends that staff should wash hands thoroughly with soap and water whenever any visible debris is present or when dealing with outbreaks caused by spore-forming bacteria such as Clostridium difficile.

Providing visitors, residents, and staff convenient access to a hand sanitizer is crucial to ensuring compliance. Facilities should encourage its guests and residents to practice proper hand hygiene frequently as part of their daily routine. Key times include before and after meals and activities and following the sharing of any hand-held items. Hand hygiene stations and additional supplies should be readily available at key locations throughout the facility including all entrances to the facility (for easy visitor access) and outside of all restrooms and resident rooms. In addition, special attention should be given to residents with mobility issues to provide sanitizing dispensers in easily accessible locations.

Touchless dispensing systems also provide added protection against the inadvertent transmission of germs.

A comprehensive education program is also an important element of any hand hygiene policy. Hospital administrators should provide their staff with annual training courses to ensure that they are being kept apprised with the most current trends and best practices. Additionally, new staff should be required to take part in hand hygiene protocol training immediately following their hiring.

Lastly, it is critical that medical staff comply with policies surrounding the use of facility-approved and supplied hand lotions. It has been proven that certain types of lotions contain properties that make some medicated soaps less effective and can cause deterioration in latex gloves. Additionally, lotions can become contaminated with bacteria if refilled improperly. Therefore, it is imperative that staff only use approved products, as well as allow the proper refilling of lotion dispensers to avoid spreading germs in their facility.

– Wava Truscott PhD, MBA, director of medical sciences and education for Kimberly-Clark Health Care

***

In recent years, hand hygiene in the healthcare setting has generated a lot of attention. Reputable organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and the Association of periOperative Registered Nurses (AORN) have all developed recommendations for best practices related to achieving proper hand hygiene. However, in my experience as an OR nurse, one area that deserves more attention is surgical scrubbing.

As I experienced firsthand in the OR, current surgical scrubbing techniques are not driven solely by guidelines set forth by organizations or individual institutions. Other factors weigh in when deciding which products to use, how they are used and how often. Three of these factors are education, habit and preference.

Education on the guidelines can indeed be helpful in understanding recommendations for surgical hand scrubbing. However, I find that many of the current guidelines leave room for interpretation, which can cause confusion. For instance, the OR staff may not realize that it is in accordance with guidelines for a waterless surgical hand scrub to be used as the first scrub of the day. In fact, an alcohol-based, waterless surgical hand scrub can potentially make it easier for the OR staff to scrub their hands quickly, with minimal effort or skin irritation. Modern alcohol-based surgical hand scrubs contain skin conditioners (emollients) that help prevent the drying effects of alcohol.

When it comes to selecting which alcohol-based surgical hand scrub to use many healthcare professionals default to habit, using traditional time-consuming methods. New waterless formulations on the market provide rapid and persistent activity against hand flora without the long scrub and dry time or sticky residue. Additionally, waterless surgical hand scrubs can be dispensed from a convenient motion-activated dispenser, which may make it easier and faster for OR staff to scrub in and comply with recommended practices.

In addition, product preference and staff input play a role in the selection of surgical hand scrubs, as they can impact compliance. Studies show an average compliance rate of 40 percent, and that poor compliance can be due to multiple factors, including perceived lack of time and irritation or dryness caused by the antiseptic. No one wants to use a scrub that doesn’t dry quickly or leaves a sticky residue, which can make putting on gloves difficult. This is why I recommend an alcohol-based, waterless surgical scrub that dries quickly, feels soft, smooth and conditioning on the hands, and leaves no sticky or tacky feel. Understanding the factors that impact surgical hand scrubbing and the product solutions available can result in best practice hand hygiene for your OR.

***

Healthcare providers have understood the importance of hand hygiene since 1847, when Ignaz Semmelweis proved the connection between handwashing and the reduction of deaths from puerperal fever. Its importance is without question; yet 164 years later hand hygiene compliance remains a huge issue.

According to the Centers for Disease Control and Prevention (CDC), healthcare-associated infections (HAIs) are a leading cause of death in the U.S., killing about 100,000 people a year and infecting about 2 million. Proper hand hygiene practices play a significant role in preventing many of these infections.

Within the Greenville Hospital System, our hand hygiene compliance was at 53 percent before and after patient care. This is quite typical when you look at compliance rates across the country. Our challenge was to rapidly increase our compliance as the cornerstone of our efforts to prevent HAIs. We set a three-year goal to achieve 90 percent compliance.

To accomplish this, we needed an accurate method to measure compliance that would allow us to have a positive impact on unit behavior, track all five essential hand hygiene “moments” or opportunities as identified by the WHO and provide real-time analysis that we could immediately act on even in the event of an outbreak.

Ideally, we wanted to move to an electronic method to give us the greatest impact. While electronic systems exist that track compliance in real-time, they don’t track against the gold standard WHO guidelines, are cost-prohibitive and have a “big brother feel” that could alienate our staff.

As a research-driven organization, our first step was creating an evidence-based model for measuring compliance based on the WHO “Five Moments of Hand Hygiene.” To do so, one of my colleagues, Connie Steed, MSN, RN, CIC, along with Elaine Larson, RN, PhD, FAAN, of Columbia University School of Nursing, and Paul Alper of Deb Worldwide Healthcare and others, conducted the “Hospital Hand Hygiene Opportunities: Where and When (HOW2)? The HOW2 Benchmark Study,” which was published in the February 2011 issue of the American Journal of Infection Control.

The study was designed to determine the average number of hand hygiene opportunities per patient day on different types of units; in different hospital types. We then worked with Deb to assist in the development and field testing of a group monitoring system that electronically monitors, tracks and reports compliance rates in real-time, based on the WHO guidelines. Through an innovative dashboard, we now have data, which combined with the benchmarks developed in the HOW2 Study, allows us to calculate compliance in real-time and feed this information back to our units.

Our approach is “measure – share – act.” This is groundbreaking for our infection preventionists, who are now able to analyze the real-life scenarios that contribute to missed opportunities and immediately implement action.

Our focus on hand hygiene has led us to a new innovation and tools that allow us to create a sustainable safety culture within our hospitals, address compliance concerns as they occur and track against the WHO guidelines. We like to think that Semmelweiss would be proud.

– Thomas Diller, MD, MMM, CPE, vice president of quality and patient safety at Greenville Hospital System University Medical Center in South Carolina

Malpractice 54.4 Billion Annually

Medical Malpractice System Accounts For 2.4% Of America’s Health Care Spending, $54.4 Billion Annually.

A new report reveals that $54.4 billion is spent annually on medical malpractice systems; 2.4% of America’s health care spending. America’s health care has existed with two separate, but related crises – its high rates of medical errors, and dissatisfaction with the malpractice liability system. The Institute of Medicine, in a 1999 study estimated that between 44,000 and 98,000 thousand patients died annually as a result of avoidable errors in inpatient hospital treatment.This perceived “crisis” has been around for much longer than people realize. Over 20 years ago, Howard H. Hiatt, a Harvard University public health experts, wrote that an “atmosphere of crisis has enveloped our system of medical-malpractice litigation and liability insurance.”
An article in the latest issue of Health Affairs tries to answer the question “What is the reality?”. Is America’s main problem too many medical errors that kill or harm patients, or that doctors and hospitals and other health care providers face the threat and reality of too many lawsuits and high insurance premiums which raise the cost of medical services as a whole? Or might it be a mixture of both things?

The report informs that recent studies have helped clear up some issues related to medical malpractice, as well as putting several myths to bed:
Myth 1. Too many claims – we all thought too many people were suing, and that claims were becoming rampantly out of control – a study revealed that a mere 1.53% of people who suffered harm as a result of medical treatment filed malpractice claims.
Myth 2. Medical malpractice claims bump up medical costs enormously – many of use believe(d) that the medical malpractice system raises the price of health care in the USA considerably. However, a new comprehensive study has revealed that it may bump up health care spending by 2.4% at the most.
2.4% may not sound like much, but in an economy the size of the USA it adds up to a lot of dollars – $54.4 billion each year; that is the amount spent on medical liability costs in America annually.

America’s over-defensive medical system leads to too many medical tests and treatments – behaviors typical of doctors trying to reduce their liability risk.

The disparity in liability insurance rates in America is unbelievable, if one goes by what this latest report quotes. The report mentions a 2003 study of seven US states – surgeons in Dade County, Florida had to pay a large insurer $174,300 annually, compared to just $10,140 for equivalent surgeons in Minnesota.

Tort reform legislation – in some states there is a limit on non-economic damages that a malpractice lawsuit can pay out. Non-economic damages include such things as pain and suffering that the patient and loved ones had to endure; it also includes wrongful death. There is evidence that some of these states are succeeding in holding down the increase in insurance premium costs.

Reforming the system may reduce the “considerable psychological cost to providers who worry about the possibility of devastating malpractice lawsuits”.

However, trying to get perceptions and reality to agree with each other is extremely challenging. According to most studies, doctors’ fears of malpractice risk are considerably greater than they should be, the report describes them as “pervasive and overstated”. Put simply, doctors imagine the worst possible outcomes, and unwittingly exaggerate the risk of their chances of occurring.

The report comments that federal health reform may help solve part of the problem. If more people have medical coverage there will be fewer individuals needing to sue in order to cover their medical expenses.

Healthcare Industry is Losing Face and Losing Money

What’s worse: Losing face or losing money?Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections — risking their reputations as sterile sanctuaries — or pay a penalty. That’s left hospital administrators weighing the cost of ‘fessing up against the cost of fines.For Clark Todd, chief executive officer of Pacific Hospital in Long Beach, Calif., there’s only one way to go: “If we hide from the public, then the tendency to keep the status quo is stronger than ever,” he said. “And that’s just not going to get the job done.”
It’s been more than a decade since a panel of top scientists declared hospital safety a national priority. Yet about 90,000 patients still die each year from preventable infections resulting from routine surgeries and hospital care, according to the U.S. Centers for Disease Control and Prevention. Examples include infections resulting from contaminated tubes that deliver food and medications, and catheters that remove urine. Staph infections, which can be deadly, are a particularly serious problem.

Many more patients are irreparably harmed. Dave Meyer of Fair Oaks, Calif., a Sacramento suburb, was a general contractor before he broke his ankle in a motorcycle accident. Records indicate he contracted an infection at a local hospital that prevented his ankle from healing. He endured several surgeries and excruciating wound cleanings.

“Imagine taking an ice cream scoop and just taking half of your foot off. It looked like just this gaping hole,” said Meyer, adding: “I know that it would have been so much better if they used the proper hygiene in the hospital.”

A Hospital Sets A Goal

Dr. Alfonso Torress-Cook of Pacific Hospital couldn’t agree more. “Hospitals are dirty,” he said. An epidemiologist and head of the hospital’s infection control program, Torress-Cook came to this for-profit teaching hospital five years ago with a clear goal: to sharply reduce the hospital’s infection rate.

Back then, the medical staff viewed infections at the 184-acute care bed facility as largely unavoidable and treated them with antibiotics, he said. The approach was costly: An infection can add $42,000 to a patient’s bill in the intensive care unit, according to the Leapfrog Group, an advocacy group that represents large employers like General Motors, Chrysler and Sprint.

Now, hand washing at Pacific Hospital, especially in the ICU, is so routine that nurses complain their hands are chapped. That’s just one of many changes. Nurses here wash patients every day. Janitors are given enough time to properly clean rooms. Even those coming in for surgery are asked to take a shower before showing up.

Torress-Cook opened a closet to show off another weapon in the hospital’s anti-infection arsenal: an ultraviolet light, hooked up to the hospital’s air ventilation system, that kills airborne germs.

At first the employees were skeptical, said Todd. But California’s new public reporting law, which went into effect in 2010, and Medicare’s decision to start withholding 2 percent of payments from hospitals that keep their rates secret, have helped his cause.

“I think that gives administrators like me even more reason to get involved in this matter,” said Todd, “and more clout with our medical staff to work against some of these traditional behaviors.”

Pacific Hospital is working to bring down bloodstream infections that result from tubes that deliver medication and nutrients. The facility has virtually eliminated methicillin-resistant Staphylococcus aureus, or MRSA, and surgical infections.

Burnishing A Hospital’s Public Image

That achievement has caught the attention of competitors and potential customers. And it’s become a source of pride for its employees.

Indeed, researchers have found that concern over a hospital’s public image is an even more powerful motivator than fear of losing market share.

“Many hospitals will measure quality and voluntarily put it up, even without the government involved,” said Michael Rapp, director of the Quality Measurement and Health Assessment Group of the Centers for Medicare and Medicaid Services. “But certainly once it’s required for all hospitals to do that, there’s the peer pressure, and they’re going to be looking at how they do compared to others.”

The fear of losing millions of dollars isn’t an idle threat. Starting this year, hospitals have to reveal their catheter-associated blood stream infections if they want their Medicare bills paid in full. Next year, they’ll have to report surgical-site infections. The list will grow longer in the coming years.

Rapp anticipates that nearly all U.S. hospitals will comply. Now, only half volunteer their data, he said.

Still, the stigma of unclean wards and fear of lawsuits can make hospitals reluctant to report. When the law went into effect in California, 19 hospitals out of 400 didn’t send in any data. State regulators, who acknowledge the first year of data collection was riddled with errors, are not imposing penalties.

There are other concerns: Competitors may undercount, making more honest players look bad, and some hospitals simply do more surgeries or have sicker patients, said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association.

“The measures aren’t perfect and don’t adequately account for the differences among patients,” said Foster.

Overwhelmed Foot Soldiers

Keeping track of the frenetic activity in their facilities can be daunting for hospitals. That’s true both in cities like Long Beach or quieter, rural areas like Ukiah, a verdant and woodsy town north of San Francisco, in Mendocino County.

At Ukiah’s small, 78-bed nonprofit hospital, patients and staff all seem to know each other, trading warm hellos on a warm spring day. It’s not hard to imagine how quickly word of even one infection can spread.

That’s something Sue Mason, a half-time nurse at Ukiah Valley Medical Center, worries about. “We have nothing to hide,” she said.

Mason has a big job and only 20 hours a week to do it: She’s charged with tracking and preventing infections.

Every morning, she checks the computerized lab tests and tries to chase down new cases. In the nationwide push for greater transparency of hospital performance, though, Mason is an overwhelmed foot soldier. She has little time to eliminate the very infections she’s charged with reporting.

“I’d like to be out on the floor more with the nurses. I could monitor their hand hygiene compliance and educate them as I see them doing their job,” said Mason. Instead, she spends most her day in front of the computer crunching data.

Mason must report not just the infections that occur, which are rare here, she said, but details of every surgery, every patient who tests positive or negative for gruesome antibiotic-resistant bugs, like MRSA.

Even at Pacific Hospital, where infection rates are some of the lowest in the nation, hospital chief Todd preaches constant vigilance. “These initiatives have to be felt with some passion,” Todd says, “and they have to be implemented with consistency and strong will.”

It will take some time before patients can know the full risk of entering their local hospital. At present, most states and Medicare publish just a short list of infections.

In the coming years, though, as the federal health law continues to take effect, the noose will tighten even more. Starting in 2012, Medicare will reduce payments to hospitals with poor infection rates in their intensive care units.

There is great hope, among researchers and hospital chiefs, that this double-barreled approach of public reporting and financial sanctions may be the best cure for what has proven to be a chronic condition in hospitals.

Medicaid to Quit Paying for Preventable Events

By Emily P. Walker, Washington Correspondent, MedPage Today
Reviewed by
June 01, 2011Review
WASHINGTON — The Centers for Medicare and Medicaid Services (CMS) has announced that hospitals and healthcare providers will no longer be reimbursed for treating their Medicaid patients for illnesses, injuries, or readmissions that should have been prevented.A final rule announced Wednesday enacts a portion of the Affordable Care Act (ACA) that prohibits states from making Medicaid payments to providers for conditions that are deemed “reasonably preventable.”In 2008, Medicare stopped reimbursing hospitals for treating conditions, infections, or illnesses that were acquired in the hospital, and for any readmissions associated with treating those hospital-acquired conditions.
The Medicaid list of what is preventable mirrors the Medicare list, which includes transfusing the wrong blood type; falls that result in dislocation, fractures, or head injuries; burns and electric shocks; catheter-associated urinary tract infections; surgical site infections after bariatric surgery or coronary artery bypass; and manifestations of poor glycemic control.
In addition, CMS has issued National Coverage Decisions stating that Medicare won’t pay for certain so-called “never events” — those which should never happen — including performing the wrong procedure; performing the procedure on the wrong body part, or performing the correct procedure, but on the wrong patient.

Medicaid will also follow Medicare’s lead on that issue and not pay for never events.
“These steps will encourage health professionals and hospitals to reduce preventable infections and eliminate serious medical errors,” CMS Administrator Donald Berwick, MD, said in a press release. “As we reduce the frequency of these conditions, we will improve care for patients and bring down costs at the same time.”

States can identify additional preventable conditions for which Medicaid payment will be denied.
The final rule is effective July 1, 2011, but gives states the option to implement between its effective date and July 1, 2012.

Since Medicare enacted its policy of not paying for preventable events, private insurers have begun to do the same.

For instance, Aetna doesn’t reimburse for eight hospital-acquired infections or for three never events, according to information provided by America’s Health Insurance Plans (AHIP), an industry trade group. Cigna doesn’t pay for never events, reduces payments for hospital-acquired infections in certain cases, and offers payment incentives for hospitals who follow standardized protocols to improve patient safety, AHIP said.

HAI in Florida HospitalsStudy on hospital-acquired infections flags Central Florida facilitiesSeveral Central Florida hospitals were among the worst in the state for life-threatening infections and conditions related to patient stays, according to recently released data from the federal government. Many had rates for falls, blood infections, even bedsores that were several times the national average.Orlando Health, for instance, had the highest rate of life-threatening blood infections in the state of Florida: four times the national average.
South Lake Hospital’s rate of falls among seniors was almost three times the national average, as was Bert Fish Medical Center’s in Volusia County.

In Daytona Beach, Florida Hospital Memorial Medical Center had a rate nearly seven times higher than the national average for foreign objects left in patients. And Leesburg Regional’s rate in that category was about five times the national average.

In the category of bedsores, Winter Haven Hospital had the second-worst rate in the state and was five times higher than the national average.

The federal government released the data based on how often Medicare patients left hospitals with infections or other problems related to their stays. The eight conditions included were blood infections from catheters; urinary-tract infections from catheters; falls; serious bedsores; blood transfusions with incompatible blood; complications from air or gas bubbles entering a blood vessel; poor control of blood sugar for diabetics; and foreign objects left in a patient during surgery.

These conditions were selected because they are “reasonably preventable,” said Shaheen Halim, director of the Centers for Medicare and Medicaid Services’ division of hospitals and medication measurement. Medicare stopped paying hospitals for treatment of these conditions in 2008.

Publishing them, she said, would give patients a view into how their local hospitals operate.

“These [statistics] measure outcomes that a patient might want to know about before choosing a hospital. They might want to see how many of these events occurred at a particular facility,” Halim said.

To gather the information, the Centers for Medicare and Medicaid Services used billing information from hospitals that treated traditional Medicare patients (those in a fee-for-service Medicare, not Medicare Advantage) from October 2008 to June 2010.

The most common condition reported was injury from a fall or some other type of trauma. More than 70 percent of hospitals reported at least one fall or trauma during the 18-month period.

Rates for infection also were common, with about 45 percent of hospitals reporting at least one blood or urinary-tract infection developed during the hospital stay. Rates were lowest for instances of blood incompatibility, which occurred once in every 1 million discharges, CMS said.

Contesting the data

Officials at Orlando Health contested the data and on May 27 sent their complaints to Medicare administrators.

Because Orlando Health’s five hospitals include the area’s only Level One trauma center, hospital officials say their system receives more traumatic — and complicated — cases than other local hospitals. Those cases are more likely to require catheters and lengthy hospital stays, hospital officials said.

In addition, Orlando Health officials complained that Medicare based its figures on billing codes, which staff can enter incorrectly — for example, mistaking inflammatory cellulitis for the more serious infectious cellulitis.

That, said spokeswoman Kena Lewis, may have led to Orlando Health appearing to have a higher rate of blood infections than was the case.

“We’re sending our comments and concerns about the methodology to CMS,” Lewis said, adding that she didn’t know whether to expect a response from the agency.

Not far behind Orlando Health for life-threatening blood infections were Shands Hospital at the University of Florida, Lakeland Regional Medical Center, Bert Fish Medical Center in New Smyrna Beach and Osceola Regional Medical Center — all of which had rates of blood infections well above the national average.

These vascular catheter-induced infections — known to most surgeons as “central line infections” — result after tubes are placed in a large vein in a patient’s neck, chest or arm and an infection occurs.

At Florida Hospital Memorial Medical Center, where the issue was foreign objects left in patients, officials disputed the findings, saying that using electronic reports to compile the data may have skewed the results.

“For example, the intentional insertion of a surgical item — such as a surgical staple to prevent internal bleeding — could be erroneously captured as leaving a surgical object behind,” said hospital spokeswoman Lindsay Rew.

At South Lake Hospital, where the rate of falls among seniors was almost triple the national average, spokeswoman Kimberly Couch said the hospital began trying to improve patient safety before the Medicare study was completed.

The hospital now conducts hourly rounds to patients’ rooms to monitor their activity and needs. That, Couch said, should reduce the risk of a patient getting up for something and falling. In addition, staffers, patients and family members are being educated about the risk of falling and how to prevent falls.

“It is always a challenge with falls to monitor patient activity while allowing for as much independent activity as possible,” Couch said. “We are confident that these initiatives will lead to improved patient safety.”

Other hospitals, including Osceola Regional and Bert Fish Medical Center, did not return requests for comment.

Where they stand

Publishing this information helps consumers and hospital officials, said Dr. David Goodman, director of the Center for Health Policy Research at Dartmouth Medical School.

“Hospitals don’t know how they stand until they receive this type of data,” Goodman said. “This helps them decide where to concentrate their efforts.”

The Institute of Medicine, an independent, nonprofit organization without ties to the government, estimates that as many as 98,000 Americans die in hospitals each year from preventable medical errors.

Patient advocates, including some doctors, applauded Medicare’s move, saying the release of the information will push hospitals to perform better.

“Public reporting is an important way of stimulating the improvement of care,” Goodman said. “The health-care profession has often looked at quality as a private matter, partly to avoid legal liability, so it has kept quality activities under wraps with the idea that health-care professionals can really measure quality and work on it without the fear of being sued.

“On the other hand, quality indicators are of obvious importance to patients,” he said. “It is information about them, and it is information that is related to their chances of getting better or worse care.”

What matters most

For consumers, Medicare’s list of eight complications may seem daunting. What should consumers pay more attention to? That, says Dr. Clifford Ko of the American College of Surgeons, depends on why you’re going into the hospital.

“If you’re undergoing surgery, then retained foreign bodies are probably more important to you” than controlling blood sugar for patients with diabetes, Ko said. On the other hand, if you or your parent is frail and likely to fall, the information on falls at hospitals may be more relevant.

Taken all together, a hospital’s scores tell consumers “how a hospital is doing,” Ko said. And he says that consumers will soon begin seeing more of this type of information from the federal government.

“I do think our health-care system is going to increase the number of metrics out there, so it will be easier for patients to get a picture of what the hospital does well,” Ko said.

Federal officials say they plan to update the data on these eight complications once a year. By doing so, hospitals can chart their progress, and consumers can stay up-to-date on how their local hospitals are performing, Halim said.

lshrieves@tribune.com or 407-420-5433

The 8 conditions

The Centers for Medicare and Medicaid Services released the data recently, posting them on its Hospital Compare website, so consumers can see how often patients leave their local hospitals with particular “hospital-acquired conditions.”

The eight conditions are:

  • Blood infections from a catheter placed in the hospital.
  • Urinary-tract infections from a catheter placed in the hospital.
  • Falls, burns, electric shock, broken bones and other injuries during a hospital stay.
  • Blood transfusions with incompatible blood.
  • Bedsores that develop after a patient enters the hospital.
  • Complications from air or gas bubbles entering a blood vessel.
  • Objects left in patients after surgery (such as sponges or surgical instruments).
  • Poor control of blood sugar for patients with diabetes.