Big changes are around the corner. As of Oct. 1, the Centers for Medicare & Medicaid Services (CMS) will stop paying hospitals for eight conditions that have evidence-based prevention guidelines. These ailments include pressure sores, catheter-associated infections, and infections associated with coronary artery bypass grafts.
The Infection Control Today CMS Series will highlight the CMS changes, reactions of healthcare professionals, and the best ways to make a business case for infection prevention. This month’s segment features infections related to urinary catheters and vascular catheters.
Some healthcare professionals see the upcoming CMS reimbursement changes as unhelpful and punitive, while others think the changes are long overdue. CMS representatives take a more neutral stance and say the changes are merely a way to make certain that payments are tied to quality of care.
This shift in reimbursements is one of CMS’s major initiatives, and was authorized by Congress in the Deficit Reduction Act of 2005, says Ellen Griffith, CMS public affairs specialist. “CMS is not asking hospitals to be guarantors against all possible adverse occurrences during a hospital stay,” Griffith says. “It is simply asking hospitals to make sure that hospital staff do what they should be doing anyway, like washing their hands before touching a patient, or observing other sanitary precautions. The underlying rationale is that neither Medicare nor the beneficiary should pay a hospital for the higher costs of treating a condition that was acquired during the hospital stay and that was determined to be reasonably preventable through compliance with widely accepted, evidence-based guidelines.”
The CMS changes could be helpful in reducing infections, such as those related to catheters, says Janet Corrigan, PhD, president and CEO of the National Quality Forum (NQF), a private-sector, standard-setting organization that endorses national standards for measuring performance and identifies strategies for improving healthcare quality. NQF has identified 28 serious adverse events from which CMS has selected a subset for reimbursement changes.
“I am hopeful that the CMS reimbursement changes will encourage providers to further intensify their efforts to reduce infections,” Corrigan says. “I don’t mean to imply that hospitals, nursing homes and other settings aren’t already working to control infections, because a lot of important efforts are underway. But we have to do more. These infections have a devastating toll on sizable numbers of patients and are very costly to treat.”
Will the Restrictions Reduce Catheter Infections?
It’s too early to measure changes and is thus not yet clear whether the new CMS policy will reduce the incidence of hospital-acquired infections (HAIs), but CMS has heard anecdotal information suggesting that hospitals are taking this policy very seriously and are implementing greater prevention steps, Griffith says. “This is a win-win for hospitals, which CMS believes really want to provide good care, for patients who will benefit from better care, and for taxpayers,” she adds.
The impact on reimbursement will be measurable but probably not catastrophic, says Rita McCormick, RN, a senior infection control practitioner (ICP) at University of Wisconsin Hospital and Clinics in Madison, Wis. As for infections related to vascular catheters, many staffs have worked hard to reduce them, and therefore the reimbursement changes might not be as dramatic as some people fear, McCormick says. “The important thing for facilities to remember is that we should be working on the prevention of these infections because it is the right thing to do for the benefit of the patient, not because we are concerned about reimbursement,” she adds.
In regard to central line catheters and urinary catheters, it is critical to remove the catheter as soon as possible. Many organizations have incorporated this belief into their multidisciplinary rounds and check catheters daily to make certain the devices are still needed, says Ann Marie Pettis, RN, BSN, CIC, director of infection prevention at Highland Hospital in Rochester, N.Y., and a member of the Association for Professionals in Infection Control and Epidemiology (APIC).
“There are care and maintenance issues with central venous catheters,” she says. “Methods for maintaining integrity and accessing the line are extremely important, particularly with late onset bloodstream infections.”
There is already a lot of attention placed on prevention of urinary tract infections, and the CMS changes will increase that focus. “The hope is that this attention can drive interventions, which ultimately will reduce infections,” Pettis says.
Healthcare professionals want what’s best for their patients and probably should not view the CMS changes with contempt, Corrigan says. “The important thing is that we all embrace this as an opportunity to refocus and amplify institution-wide efforts to enhance safety,” she adds.
McCormick believes that some healthcare practitioners may be worried about the CMS changes, but that others are more welcoming. “I am guessing that the infection control specialists may secretly welcome the changes as it brings the subject to the attention of senior administration, which is a good thing,” she says.
Practitioners are expressing a wide range of opinions, Pettis observes. “Some ICPs welcome the CMS changes, indicating that attention to infection prevention is long overdue,” she says. “The CMS measures highlight the fact that infection prevention is both a quality and financial measure. Others are skeptical, given the fact that outcomes will be measured by administrative, rather than surveillance data. That may result in a tendency for some institutions to overreact, putting even more pressure on ICPs and care providers.”
Pettis says that in an effort to identify infections that are present before patients are admitted, some organizations have proposed obtaining unnecessary urine cultures or other tests for patients upon admission, and these may actually drive up healthcare costs.
In the face of reduced reimbursement, administrative leadership will focus even more on creating a stronger culture of safety by changing the care process and educating staff, patients and caregivers, Corrigan says. Pettis agrees that administrators will pay more attention to infection prevention, and that there will be more education. These changes, however, cannot be ramshackle or random.
“The challenge will be to ensure that we take a thoughtful, organized approach and continue to implement evidence-based interventions,” Pettis says. “Also, when it comes to education, it needs to be interdisciplinary rather than focusing on a single discipline, such as nursing.”
McCormick echoes that view and says, “It is not enough to educate if what is taught is not put into practice. Administrators play a role in making sure that practices are monitored and changes in practice are made when indicated.” She adds that she is not sure how or if administrators will change their staff education now that “CMS will be a value-based purchaser rather than a passive payer.”
It’s high time for infection prevention to be at the forefront. Traditionally, infection prevention hasn’t gotten much attention, McCormick says. “In my opinion, administrators have been working diligently in areas of patient safety — prevention of medication errors, falls and the like — but for some reason they do not view prevention of infection in the same light as other patient safety measures — which of course it is — but it hasn’t gotten the same emphasis,” she adds.
Making the Business Case for Infection Prevention
It’s hard to believe, but some major decision-makers in the healthcare industry still don’t understand that preventing infection not only saves lives, it saves money. Fortunately, the CMS reimbursement changes will “absolutely” help infection control practitioners (ICPs) make the business case for infection prevention to their administrators, Corrigan says.
“These infections now have a negative impact on the hospital’s bottom line,” she adds. “The financial return on investments in infection control has just gone up. This should make it much easier for ICPs to get the attention and support of senior management.”
McCormick agrees that the changes can help. “Yes, I would expect it to have an impact for some; others may be too far removed from their administrators or do not have access to the additional expenses incurred in order to make their case,” she says. “The change in reimbursement offers a good opportunity for ICPs to get to know the people at the fiscal end with the intent to work together and make the business case if this has not already been done.”
Pettis agrees that ICPs currently have a unique opportunity. They can strengthen that position by reviewing cases and determining if there were areas for improvement. “ICPs can work with a multidisciplinary team to do a ‘mini’ root cause analysis to identify deviations from the ‘normal pattern’ and to identify learning opportunities that can be extrapolated from patterns and failures,” Pettis says. “The main suggestion I would make is to work closely with both the financial and coding departments. This may be an opportunity to help educate physicians as well and to demonstrate our value to administration.”
How to Fight Catheter-Associated Infections
The decision by CMS to not reimburse hospitals for the additional cost of treating patients who acquire a catheter-associated urinary tract infection (CAUTI) during their hospitalization has made infection prevention even more of a priority, says Jim Liddell, infection control and urology product manager of Bard Medical Division.
Urinary tract infections account for up to 40 percent of all HAIs, and the majority of these infections are associated with urinary catheters,” Liddell says. “Because of the high frequency of these infections, they can create a tremendous clinical and economic burden for the healthcare facility,” he adds.
Liddell recommends that healthcare teams reduce CAUTIs by inserting catheters properly, and by using clinically proven anti-infective Foley catheters, such as the Bardex® I.C. Foley Catheter.
As for vascular infections, certain evidence-based recommendations can be helpful and include the following areas:¹
educating healthcare providers who insert and maintain catheters
using maximal sterile barrier precautions during central venous catheter insertion
using a 2 percent chlorhexidine preparation for skin antisepsis
avoiding routine replacement of central venous catheters
using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies
The way a device is secured can affect infection probabilities, says Gregory Schears, MD, a pediatric intensivist and board-certified anesthesiologist at the Mayo Clinic in Rochester, Minn. He conducted a study that compared and contrasted peripheral IVs that are held with tape versus StatLock, a catheter stabilization device.²
Schears says with StatLock, the catheter is on top of an adhesive pad and is attached. “The pad provides a large, uniform adhesive surface that adheres to the skin, so the adhesion is less likely to be disrupted than with the traditional method of placing the catheter on the skin and placing tape on top of it,” he adds.²
The difference affects patient safety. Stabilization devices result in 76 percent fewer restarts than tape, and lower rates of phlebitis, movement and irritation.² Not everything is this tangible or correctable. Diabetes, obesity, smoking and other patient-specific issues, for instance, increase the risk of certain infections, Pettis says, and those are difficult for practitioners to mitigate.
“Not all risk factors can be controlled, but if we work together as a multidisciplinary team, we would expect to see a reduction in adverse events,” Pettis says. “Agree with them or not, the CMS guidelines are here to stay. The good news is that they may better position our programs and strengthen the role of ICPs in our organizations.”
1. O’Grady NP, et all. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Pediatrics. November 2002.
2. Pyrek KM. Study changes the course of clinical thought on catheter securement. Q&A with Gregory Schears, MD. Infection Control Today. January 2007. www.infectioncontroltoday.com/articles/410/72h2212104084322.html