High Cost of Hacs- New Reduction Program Impacts Reimbursements

OR Today | Cover Story | High Cost of HacsBy Don Sadler

Last year, the Centers for Medicare and Medicaid Services (CMS) launched a renewed effort to reduce the frequency of hospital-acquired conditions (HACs) among hospitalized patients.

The newest CMS Hospital-Acquired Condition Reduction Program was mandated by the Affordable Care Act and builds on the CMS’s previous HAC reduction program that was established under the Deficit Reduction Act of 2005. It became effective last October and ranks most U.S. hospitals against each other with regard to the frequency of hospital-acquired conditions occurring within them.

How the HAC Reduction Program Works

Each one of nearly 3,000 U.S. hospitals now receives a Total HAC score of between 1 and 10 — the higher the score, the worse the hospital has performed under the CMS HAC-Reduction Program. Hospitals that rank in the bottom quartile of HAC performance with a Total HAC score of 7.5 or higher will now lose one percent of their CMS IPPS reimbursements.

OR Today | Cover Story | High Cost of HacsAccording to Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP Director, Evidence-Based Perioperative Practice for the Association of periOperative Registered Nurses (AORN), it appears that the new CMS HAC Reduction Program was necessary because the original CMS program had little impact on reducing HACs.

“We first started talking about hospital-acquired conditions in 1999 when ‘To Err Is Human’ was first published by the Institute of Medicine,” says Spruce. “However, it doesn’t look like we have improved in this area very much over the past 15 years.”

In a preliminary analysis of the new CMS HAC Reduction Program conducted in April, more than 721 hospitals were assessed sanctions of approximately $371 million. This represents an average of 18 percent of a hospital’s operating margin.

“In addition, approximately one out of every eight hospital patients in the U.S. suffers a potentially avoidable hospital-acquired condition,” says Spruce.

“The CMS HAC Reduction Program is attempting to improve HAC performance at U.S. hospitals by penalizing the worst-performing hospitals with regard to HACs,” Spruce adds. “Unfortunately, drastic action was needed because hospitals weren’t improving performance on their own.”

What Are HACs?

The term “hospital-acquired condition” describes any condition affecting a patient that arose during a hospital stay. It encompasses a wide range of conditions, which include but are not limited to:

• Hospital-acquired infections (HAIs)

• Surgical site infections (SSIs)

• Accidental punctures and lacerations (APLs)

• Central line bloodstream infections (CLABSIs)

• Catheter-associated urinary tract infections (CAUTIs)

• Deep vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures like total knee replacement and hip replacement

• Foreign objects retained after surgery

• Falls and trauma

• Patient burns

• Stage III and IV pressure ulcers

The Total HAC score is determined by several different HACs, but mainly APLs, HAIs, CLABSIs, CAUTIs and other patient safety indicators.

In fact, CAUTIs are the most frequent type of HAI, accounting for 40 percent of all HAIs. One CAUTI results in an average of $3,383 in additional treatment costs and 4.6 additional days in the hospital, and approximately 13,000 deaths each year are attributed to CAUTIs.

However, APLs carry the most weight in the Patient Safety Indicator Composite (PSI-90) ratio. This is a weighted measure based on eight individual patient safety indicators that is a key component in determining the Total HAC score.

OR Today | Cover Story | High Cost of HacsCommon APLs during laparoscopy procedures include stray energy burns and energy burns within the visual field, says Jeffrey L. Eakin M.D., a laparoscopic and robotic gastrointestinal and bariatric surgeon with Physician Group of Utah, Jordan Valley Medical Center, in Salt Lake City, Utah.

Eakin recommends using advanced technologies like the Ethicon Harmonic Scalpel, the Coviden Sonicision, and the Encision AEM Endoshield burn protection system to eliminate stray energy burns.

“This technology shuts the instrument down if it senses any possibility that electrical current could be leaking out that might lead to a patient burn, thus reducing the potential for human error,” he says. “Relying on luck is not a good system to have for reducing APLs.”

HACs can happen immediately in the OR or later after the surgery is complete, Eakin adds.

“For example, wound infections usually don’t transpire until some time after surgery,” Eakin says.

“The same thing goes for CLABSIs and CAUTIs,” Eakin adds. “If catheters are not handled properly, there is an increased risk of bloodstream infections from common bacteria.”

Eakin stresses that urinary catheters should be removed as quickly as possible post-op, preferably within 24 hours. Also, proper sterile technique should be used and protocols utilizing best practices followed to reduce CLABSIs.

Evidence-based recommendations for preventing CLABSIs include the following:

• Educate and train all health care personnel who insert and maintain catheters.

• Use maximum sterile barriers and proper hygiene techniques during catheter insertion and handling.

• Avoid routine replacement of catheters as a strategy to prevent infection.

Spruce stresses that evidence-based practice guidelines exist and should be followed for almost every type of HAC.

“These are practices that have been proven to work in reducing HACs, so it makes sense to know and follow them,” she says.

In addition, AORN has published guidelines and tool kits designed to help reduce many HACs, says Spruce, including foreign objects retained after surgery, ALPs, sharps safety, fire safety, and patient positioning and handling.

Patient burns are another type of HAC that is more common than many health care professionals realize. Over a 10-year period in the U.S., patient burns resulting in thermal bowel injury have led to more than 16,500 patient complications and 4,000 preventable patient deaths.

Data Tracking and Analysis

Spruce believes that data tracking and analysis is one of the most important keys to reducing HACs.

“Hospitals need to track data carefully to determine the areas where HAC improvements are most needed,” she says. “This data needs to be clinically based so hospitals can capture safety events as they happen in real time.”

For example, electronic health records (EHRs) can track data automatically, Spruce notes.

“Data needs to be actively captured, rather than passively reported,” she says. “Once you do this, you can improve your processes in ways that will help prevent HACs. And the technology can help you monitor your processes to gauge compliance with the CMS HAC Reduction Program.”

Hospitals can realize a number of concrete benefits by severely reducing or eliminating HACs, including:

• Avoiding a reduction in CMS IPPS reimbursements, which will help maintain operating margins.

• Shorter hospital stays for patients and lower patient readmission rates, resulting in higher levels of patient satisfaction.

• Improved hospital reputation in the marketplace.

• Avoiding costly and time-consuming patient lawsuits.

• Better operational efficiency in the hospital.

Spruce points out that hospitals’ Total HAC scores are made available to the public — they are posted on the Medicare Hospital Compare website at data.medicare.gov. As a result, patients can make more informed hospital choices by comparing and choosing the best hospitals based on their history of HACs.

“This will hit hospitals in the pocketbook in terms of reduced CMS reimbursements and fewer patients choosing to have surgeries performed there,” says Spruce. “So it is in the best interest of hospitals to do everything they can to reduce incidences of hospital-acquired conditions.”