Friday, July 13, 2012

The "Never Events" list should be reconsidered

You are probably familiar with the CMS “never events” initiative. CMS has decided it will not reimburse hospitals for treatment related to complications which it says should never occur. Here is the current list.
  • Foreign object retained after surgery
  • Air embolism
  • Blood incompatibility
  • Stage III and IV pressure ulcers
  • Falls and trauma
  • Manifestations of poor glycemic control
  • Catheter-associated urinary tract infection
  • Vascular catheter-associated infection
  • Surgical site infection after coronary artery bypass graft, bariatric surgery for obesity and certain orthopedic procedures
  • Deep vein thrombosis/pulmonary embolism after certain orthopedic procedures
According to American Medical News, two more complications have been proposed as additions. One is acquired conditions stemming from cardiac implantable electronic device surgeries and the other is iatrogenic pneumothorax associated with venous catheterization.

I have no problem with some of the items on the list. Foreign bodies like sponges or instruments should not be left in patients after surgery. Air embolism and blood incompatibility should be 100% preventable.

But I do not see how catheter-associated UTIs or vascular catheter associated infections can be completely prevented. Some sick patients with depressed immune systems are going to get infections.

I believe it is impossible to completely prevent wound infections in all clean cases. As has been shown in studies of SCIP compliance, some patients get wound infections after colon surgery despite the timely use of the right antibiotic.

DVT/PE cannot be prevented in every orthopedic procedure. I am unaware of any DVT study in which no patients in the experimental arm developed DVTs or PEs. Patients will develop DVT or PE even with the best evidence-based care.

With very few exceptions, every large published paper on central line insertions, even those using ultrasound guidance, reports some instances of post-procedure pneumothorax. There is no way it can be completely avoided. For example, this study of 937 ultrasound-guided central line insertions reported 2 (0.2%) post-procedure pneumothoraces. That’s a published study by radiologists. The real world incidence of pneumothorax is much higher, often quoted at 2-5%.

To me, these rulings are simply a way for CMS (and other payers who are sure to follow suit) to avoid paying. Where is the input from “organized medicine”? Was any evidence-based research looked at by those who decided all this?

Why are we standing around and allowing this to go unchallenged?

This post appeared on Sermo yesterday and most people who commented agreed with me.


Unknown said...

agree...esp catheter related infections. I even believe some stage 3 ulcers are hard to prevent. I worked as a wound nurse. No matter how hard you try to prevent some of the ulcers, no matter how much you turn a patient, treat the wound some just get worse. Especially in patients that refuse to eat the correct diet, get off the area that is infected or other factors. I agree with some areas that can be prevented. If they can prove negligence then I agree they should not have to pay. But if it truly wasn't avoidable they need to kiss off.

Skeptical Scalpel said...

Suzanne, good point about the prevention of ulcers. The rule assumes they all are solely the fault of care-givers.

mdaware said...

there are also some clear conflicts between some of these goals -- if you want to prevent falls, some people will need to be bedbound, at higher risk for VTE, decubs, and catheter-related infections.

Skeptical Scalpel said...

MD aware, Good point. You are correct. I hadn't thought of that. It's a no win situation.

Todd J. Scarbrough, M.D. said...

"I'm sorry doctor, but it's hospital policy not to allow indwelling catheters in any of our patients. The infection and non-payment risks are far too high."

Skeptical Scalpel said...

Let their bladders expand until they rupture. Then we can code for bladder repair.

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