I told you so.
Three months ago, I blogged
about the Medicare (CMS) “never events” list, diagnoses that Medicare will no
longer reimburse hospitals for. In Medicare’s eyes, these diagnoses are totally preventable,
should never happen and will not be reimbursed. I pointed out that several were
in fact not 100% preventable despite any institution’s best efforts, and the
rates of many of these occurrences would not fall to zero.
Now the esteemed New England Journal of Medicine has published
a paper
which confirms what I wrote back in July. Its 13 authors compared rates of
central line-associated bloodstream infections (CLABSI) and catheter-associated
urinary tract infections (CAUTI), two of the diagnoses on the “never events”
list, with ventilator-associated pneumonia, a disease not on the list, as a
control.
After reviewing data from 398 hospitals from before and
after the establishment of the new Medicare rules, they found that quarterly
rates of all three infections did not change and concluded that the “never
events” policy was ineffective. The senior author of the study then tweeted “Our
paper in NEJM - CMS non-payment policy didn't change infection rates. Do we
need much stronger penalties?”
My answer to that question is “No.”
Penalizing hospitals did not work because we may have
reached the lowest possible rates of infection already. Some infections will
occur no matter what steps are taken. We are dealing with human patients and
human care-givers. Perfection is not likely to happen.
Many people erroneously believe that all CLABSIs can be
prevented with the implementation of strict sterile precautions when catheters
are inserted. That has lowered infection rates but not to zero. Why not? In
addition to the technique of insertion, CLABSIs can result from other factors.
Solutions may become tainted. The integrity of the IV line itself may be
violated during the administration of medications through the line. The dressing
covering the line may loosen and allow bacteria to enter the puncture site.
Patients may be immunosuppressed and unable to overcome even the slightest hint
of contamination. Or maybe it’s just bad luck.
CAUTIs are also not totally preventable. Despite a major
push to remove urinary catheters as soon as possible, some patients need them
for days to weeks for many reasons. For example, there are patients who simply
cannot urinate on their own due to old age, dementia, coma, paralysis, etc. Critically
ill patients with marginal urine outputs need urinary catheters for monitoring.
Patients who are incontinent of stool may contaminate their catheters despite
the best nursing care.
No, much stronger penalties will not work.
How about if we simply decide what is an acceptable rate for
these infections and aim for that?
7 comments:
As a pre-clinical medical student, I may be speaking out of turn here, but I don't understand the reason for the policy. I would like to believe that no hospital would intentionally infect a patient as described for financial gain.
I'm all for CMS cuts that prevent fraud, abuse, and unnecessary procedures, but this policy only hurts the patients, assuming they get stuck with the bill. Even if patients don't get billed, how will the hospital's response and care of the infection change with the proposed cuts in mind?
You have summed it up very concisely. We will never have a 0% nosocomial infection rate, despite all of the high quality nursing and other interventions that we do to try to prevent infection.
Thanks for commenting.
huhet, I agree. Despite what you might think if you look at newspapers or Twitter, we are not trying to hurt people. That's why penalizing us when things that cannot be avoided happen does not work.
At, I appreciate your agreeing with me.
Simply, our bodies were not designed to take any of this stuff. This is the main variable that no one can eliminate. Sure we can be watchful on how to do things better, but the fact remains.
Bacteria evolves faster than we can evolve. More patients will have a rough ride through invasive treatment as time goes. New and different fears will arise.
Legislation of this kind is a waste of billions that could go to better use ...research.
-SCRN
While it is true that CLABSIs (and other nosocomial infections) will never reach 0%, the infection rate can be reduced substantially. There are a number of studies that show CVC infection rates can be lowered through implementation of process measures (such as compliance with the IHI bundle) and checklists. In our own hospital we have reduced our CLABSI rate by 400% over 4 years through an intensive intervention including retraining and credentialing all providers in US-guided CVC placement, educating nursing staff in line care, and a QI process with checklists and tracking of all infections.
As always it sounds like a good idea with good intentions, but in the end it failed. Aiming for zero is a respectable goal, but not realistic with the current technology.
Very good article, thank you for posting.
Good comments. Infection rates may have been reduced as much as possible. But I don't think they can ever reach zero.
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