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Tick-tock … tick-tock.

By now, there shouldn't be an administrator, provider or facility unaware of the Centers for Medicare and Medicaid Services pending reimbursement changes for selected hospital-acquired infections (see box). Despite the ticking clock, however, concern exists that some facilities remain unprepared.

A speaker at the Surgical Infection Society's 28th Annual Meeting and a widely recognized expert in fighting infection, Addison May, MD, recently shared his thoughts on the coming reimbursement changes and steps hospitals need to take to minimize liability. May is the medical director for the Surgical Intensive Care Unit at Vanderbilt University Medical Center and a professor of surgery for the School of Medicine.

"The change in the rules has both benefits and significant drawbacks," he stated. "The drawbacks really relate to the fact that not all infectious complications can be prevented."

May noted that a major concern for tertiary and quaternary facilities is that these referral hospitals disproportionately care for patients who are at higher risk for infectious complications including bearing a higher load of indigent care, trauma patients and complex long term care cases.

"While you can certainly reduce the number of infections by implementing both complex and simple maneuvers, you cannot eliminate them," he noted.

Still, May stressed, that doesn't mean you shouldn't try.

The cost … both in terms of hard dollars and human toll … is sobering. An updated report by the Centers for Disease Control and Prevention estimates 1.7 million patients annually contract nosocomial infections. Additionally, the CDC now estimates healthcare-acquired infections (HAIs) account for 99,000 associated deaths each year … up from previous estimates of 90,000 annual deaths.

"By not paying for infectious complications, you are creating a financial incentive for hospitals to put energies into reducing those complications," May said of the reasoning behind the CMS reimbursement cuts.

"I suspect there will be a 'give and take' over time … as with any big federal program, it won't be implemented correctly the first time" he added.

May noted that he believed CMS would closely monitor the financial impact of the rules change. Improvement in our national ability to capture data makes it easier for the federal government to assess patient acuity. If the reimbursement changes ultimately threaten the viability of tertiary and quaternary hospitals serving the highest risk patients, reimbursements could potentially be tweaked to offer a higher rate of return for caring for critically ill patients. However, he said that even if such a change occurred down the line, there would still be a negative impact for overlooking necessary steps to avoid preventable conditions.

While clinicians have long touted the advantages of using technology and newer devices, such as antibiotic-coated catheters, to help reduce infections and avoid mistakes, the financial benefit hasn't always been immediately apparent to those in charge of the bottom line.

"It is markedly more straightforward now for someone who is in a business position in the hospital (to see) how spending money on devices that reduce infectious complications is a financially worthwhile endeavor," May said.

Even with buy-in from everyone, however, mistakes still happen … particularly in emergency situations where decisions must be made quickly, and patients are handed off between a number of caregivers from first responders to paramedics to ER doctors to a variety of nurses and physician specialists.

The best option for minimizing preventable errors, May said, is to expend energy and money to ensure the correct processes are in place and are understood by the full staff.

"Well-proven standards have been out there in publication for at least 10 years," he said of best practices to avoid the most common preventable events such as urinary tract infections, pneumonia, pressure ulcers, surgical site infections and bloodstream infections.

For example, he continued, there are well-documented precautions that should be taken with the placement of a central venous catheter or other device. May said clinicians should take "full sterile-barrier precautions" including following the guidelines for the appropriate use of caps, masks, sterile gowns and gloves; creating a large area drape; and prepping the space with chlorhexidine. Other documented best practices include using antiseptic or antibiotic-coated catheters in high-risk patients and appropriately maintaining intact dressings without fluid collection underneath.

Similarly, May said there are known precautions that should be taken for the prevention of skin breakdown and pressure ulcers.

"It's again a process where the maneuvers are not necessarily difficult. However, one has to have effective systems in place to recognize patients at risk, apply appropriate preventive measures in a very timely fashion, with a high rate of performance compliance (among staff), all in a very complex and labor intensive setting" he said.

Further complicating the issue, May added, is the realization that nosocomial complications such as infection or early skin breakdown may be present before patient arrival to the hospital but not readily detectable. He pointed out that some infections might develop over several days before a patient becomes symptomatic, and culture results could take several additional days to return. In general, though, he said that hospitals would "absolutely" be testing at least high-risk patients as part of the routine admission process. CMS will continue to reimburse for care given to combat those infections documented to be present upon admission.

May said more hospitals would have to rely on technology to help ensure a consistently high level of compliance with preventive measures. Multiple programs are now becoming available where providers receive reminders about best practices in real time.

"Care has become so complex that it exceeds a human being's ability to do a process consistently without mistake," May pointed out. He added that the costs for providing such programming are becoming more affordable.

In the end, the majority of tools used to reduce the risk of HAIs are typically fairly low in cost but do require commitment from the top down. The most effective facilities having a team in place to ensure staff is adequately trained, evidence-based guidelines are routinely followed as exactly as possible, and outcomes are continually monitored.

"The takeaway for hospitals is that many of the things that can be done to reduce problems can be done inexpensively but cannot be done unless there is an appropriate alignment of the hospital systems and patient care providers," May stressed.

"Most hospitals should be able to drop their rates to almost zero … but never zero," he concluded of a realistic goal for minimizing HAIs and maximizing reimbursements.

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