Compliance Mentor - October 2015

Hospital Access Management - Hospital Case Management - Hospital Employee Health
Hospital Infection Control - Hospital Peer Review - Healthcare Risk Management
Case Management Advisor - IRB Advisor - Medical Ethics Advisor - Same-Day Surgery

Preventing Catheter-Associated UTIs

Urinary tract infections can involve any part of the urinary tract system, including the bladder, ureters, urethra, or kidneys. Most UTIs (75%) are associated with a Foley catheter or an indwelling catheter. There has been a push to reduce the number of catheter-associated UTIs by ensuring there is proper indication and that they are removed as soon as no longer necessary.

Motivated by the high rate of infection, and based on the CDC’s 2009 “Guideline for the Prevention of Catheter Associated Urinary Tract Infections” and their “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update”, The Joint Commission has proposed changes to all five of its elements of performance under NPSG.07.06.01. Under the proposed changes hospitals will be required to implement evidenced-based practices to prevent catheter-associated urinary tract infections (CAUTI).

The hospital will have to educate staff and LIPs who are involved in the use of Foley catheters, during orientation and then annually. Hospitals will need to develop written criteria for placement of a Foley. This criteria may include critical patients who need accurate urinary output monitoring. There must also be procedures on when it is appropriate to insert and maintain a Foley. The hospital’s guidelines would also need to include hand hygiene, how to secure the Foley, how to use aseptic technique in inserting, how to collect samples, how to maintain sterility of the system, and the requirements for educating patients and their families.

CMS has a catheter-associated tracer that is located in its infection control worksheet that all hospitals should be familiar with. Every hospital is required to have guidelines for the appropriate indications for urinary catheters.

1. There must be documentation indication for the catheter insertion.
2. Staff must do hand hygiene before and after insertion.
3. The catheter must be secured after insertion.
4. The bag must be below the level of the bladder.
5. Staff should ensure he tubing is not kinked or disconnected and irrigation should be avoided.

In summary, hospitals who are accredited by TJC should be aware of the proposed changes and any hospitals that received Medicare reimbursement should be familiar with the CMS infection control worksheet.

Resources:

• The Joint Commission’s proposed revisions to the National Patient Safety Goal on Catheter Associated Urinary Tract Infections can be reviewed here.
• “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update” is available here.
• Catheter-associated urinary tract infection resources for the CMS Partnership for Patients, including links to many toolkits and other useful resources, can be found here.
• The CDC’s website on catheter-associated urinary tract infections includes recommendations along with many resources, FAQs, prevention and toolkits, podcasts, slide presentations and information on monitoring catheter-associated UTIs through the National Healthcare Safety Network.
• The CDC’s “Guideline for the Prevention of Catheter Associated Urinary Tract Infections” is here.
• FAQs about catheter associated urinary-tract infection is here.
• The CMS worksheet on infection control is available here.

Related [Live Webinar] October 28: National Patient Safety Goals for Hospitals

Related [Live Webinar] November 10: Infection Prevention & Control Standards from CMS: the Latest.

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New Guidelines for Helping Prevent Patient Falls

Preventing patient falls is always a hot topic, especially at hospitals. A CDC fact sheet says one out of three older persons fall each year and one of every five falls causes a serious injury, such as fractures and head injuries. When patients fall in the hospital, it is not only a patient safety or risk issue but often a financial issue.

CMS has identified hospital-acquired conditions as instances in which there is no additional payment from Medicare. For instance, if a Medicare patient falls and suffers a subdural hematoma, is in intensive care for four days and then dies, the hospital will not be reimbursed for expenses related to the fall.

The Joint Commission wants hospitals and healthcare facilities to pay more attention to falls. TJC notes that 30-50% of all falls result in an injury. The JC recently issued Sentinel Event Alert 55 on preventing falls and fall-related injuries in healthcare facilities. Elderly patients are not the only ones at risk. Patients of any age can fall due to medications, surgery, procedures, or diagnostic testing that can leave them in a weakened or confused condition.

TJC recently published a targeted-solution tool for preventing falls. Falls, on average, add 6.3 days to the length of stay and cost about $14,056. The hospitals in the pilot had impressive results in using the tool which reduced falls by 35% and fall injuries by 62%. The targeted solution tool is complimentary to TJC accredited organizations. However, staff at every hospital and healthcare facility should read the JC documents on falls and implement any recommendations not currently being followed.

The most common contributing factors to falls are inadequate assessment, communication failures, lack of adherence to policies and safety practices and inadequate staffing or staff orientation. TJC data published July 9 states that from 2004 to the present, there were 750 falls with 91 being reported in 2014, making falls the second most frequent sentinel event in 2014. It was the fifth most common one in 2013 and the sixth in 2012.

To prevent falls:

• Assess staffing to ensure there are enough employees to prevent falls.
• Use preventive equipment such as alarms.
• Have an educated and interdisciplinary falls committee.
• Use a validated tool to assess the risk for falls such as the Morse Fall Scale or Hendrich II.
• Standardize hand-off communications when giving reports.
• Individualize the patient plan of care.
• Conduct post-fall management that includes a post-fall huddle.

Other initiatives to minimize falls:

• Regular analysis of medications.
• Safe room set up, toileting, hourly rounding, and safety signage.
• Identification of high-risk patients with bracelets or visual clues like blankets, socks or signage on the door or over the bed.
• Creation of no-pass zones in which anyone who can see the call light must respond whether it is their patient or not.
• Creation of a personalized recorded message added to the call light.

Resources:

• “CDC Important Facts about Falls” is available here.
• More information from CMS on hospital-acquired conditions can be read here.
• TJC Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care facilities, issued September 28, is here.
• More information about the JC’s new targeted solutions for preventing falls is available here.

Related [On-Demand Webinar]: Give Falls the Slip: TJC & CMS Hospital CoPs & Standards

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Hospitals: Make Sure Your Vendors Meet Your Standards

The CDC issued a Health Alert Network Update on Oct. 2 regarding the requirement that hospitals must verify that any vendors who maintain, clean, disinfect or sterilize reusable medical devices are certified or approved.

Recent infection-control lapses due to noncompliance with recommended processing indicated a critical gap that put patients at risk. The affected patients were notified that they may be at risk for infection because equipment was not disinfected or sterilized properly.

The CDC issued the alert after being contacted by multiple healthcare facilities to determine who is available to certify or approve vendors. Currently, there are no formal or standardized programs through which a facility can verify that a vendor or contractor has the appropriate training. However, the CDC clarified that hospitals and other healthcare facilities who hire contractors to perform device processing confirm that those contractors have appropriate training programs. It is imperative that the program include device specific training.

Hospitals and other healthcare facilities should also train any of their own staff who will be processing medical devices. This would include semi-critical items such as endoscope processing and laryngoscope blades and could include reprocessing critical items such as surgical instruments. Staff should be trained in orientation and thereafter at least once a year.

Manufacturer’s instructions should be available on how to clean, operate and process the equipment and training updates should be done, for both staff and vendors, when changes are made. To ensure proper cleaning, disinfection, sterilization, and storage, regular audits should be conducted.

Resources:

• Hospitals can sign up for Health Alert Network email updates here.
• The CDC’s Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 is here.
• Guidance from the Association for the Advancement of Medical Instrumentation is here.

Related [Live Webinar] November 10: Infection Prevention & Control Standards from CMS: the Latest

Related [On-Demand Webinar]: Contracted Hospital Services: Certifying Compliance with CMS, TJC & DNV

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Report on Hospital Purchasing Programs Shows Little Progress

The Government Accountability Office’s recent 49-page interim report on value-based purchasing programs shows that hospital performance on quality measures was improving before the purchasing program was instituted and has not noticeably changed during its first two years. The report found no apparent shifts in hospital performance trends on quality measures from fiscal years 2013-15.

The program, part of the Affordable Care Act, was created to reward hospitals for quality care. It was designed to move healthcare delivery away from payment for volume to one that pays for value and quality care for inpatients.

Most of the approximately 3,000 hospitals eligible for the program received a bonus or penalty of less than 0.5% of their Medicare payments in each of the program’s first three years. Seventy-four percent of hospitals inside the range at the end of the fiscal year ending Sept. 30 had a $39,000 median bonus and a $56,000 median penalty.

Outliers of the payments and penalties only serve to point out some trends that need to be addressed. A recent article in JAMA Internal Medicine found that relying on the current risk-adjustment characteristics of age, sex, and diagnosis put safety-net hospitals in line for significant financial penalties due to higher readmission rates. Safety-net hospitals, serving the poor and patients with chronic conditions, had smaller bonuses and larger penalties.

Bottom line? The program has failed to demonstrate improvements in care.

Resources:

• The October 2015 GAO report “Hospital Value-based Purchasing” is free here.
• More information on the report from CMS can be found here.
• See Patient Characteristics and Differences in Hospital Readmission Rates, Michael l. Barnett, MD, John Hsu MD, MBA, MSCE, J. Michael McWilliams, MD, PhD, JAMA Intern Med. 2015; doi: 10.1001/jamainternmed.2015.4660.

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