Hospital Consult - February 2016
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
Changing Skin Prep Antiseptic Combination Lowers C-section Infections
ST. LOUIS – A new study is urging hospitals to change standard skin-prep practices for cesarean sections.
With more C-sections each year in the United States than any other major surgery, the procedure carries a significant rate of infection at the incision site, according to the report appearing online in The New England Journal of Medicine to coincide with a presentation at the Society for Maternal-Fetal Medicine's Annual Meeting in Atlanta.
Based on their research, Washington University School of Medicine-led investigators suggest that, instead of prepping C-section patients with the commonly used antiseptic combination iodine-alcohol, hospitals use a chlorhexidine-alcohol combination.
"One of the biggest complications of surgery, and of C-sections in particular, is infection," explained first author Methodius G. Tuuli, MD, assistant professor of obstetrics and gynecology at Washington University School of Medicine. "For a new mother who needs to care for her baby -- which is stressful even when all things are equal -- having an infection can really impair her ability to do that.”
For the clinical trial, researchers randomly assigned 1,147 patients who underwent C-sections at Barnes-Jewish Hospital from 2011 to 2015 to receive either iodine or chlorhexidine combined with alcohol for skin prep. Results indicate that 23 of the 572 patients receiving the chlorhexidine-alcohol combination developed an infection at the surgery site within 30 days, compared to 42 of those receiving the iodine-alcohol combination.
The new study was conducted at only one hospital, but researchers emphasize that the patient population was racially diverse and that more than 60% of participants received public insurance.
In addition, study authors pointed out that the chlorhexidine-alcohol combination was superior whether the C-section was scheduled or unscheduled, whether the patient was obese, whether staples or sutures were used to close the wound and whether the patient had chronic medical conditions, including diabetes.
Improving the infection rate could have a significant effect on costs, according to the article: Surgical site infections currently complicate 5% to 12% of the 1.3 million C-sections in the United States, at an average cost of $3,500 for treatment.
“There are few circumstances when a single study should change our practice,” senior author George A. Macones, MD, said in a Washington University press release. “But based on the biological plausibility and the striking reduction in surgical-site infections with chlorhexidine, this is one of those circumstances.”
Identifying Characteristics of Children With High Hospital Costs
BOSTON – The top 10% of the children with the highest annual inpatient cost (CHIC) made up more than half of total inpatient costs in 2010 for 39 U.S. pediatric hospitals, according to a new study.
Yet, most of those children had no hospital costs over the next two years, according to the report in the journal Pediatrics.
In an effort to find out how hospitals can contain costs while providing care for children with high healthcare expenses, a study team led by Boston Children’s Hospital researchers undertook a retrospective study of 265,869 children age 2 to 15 years with one or more admission in 2010 to 39 children’s hospitals in the Pediatric Health Information System.
For the study, CHIC were defined as the top 10% of total inpatient costs in 2010, representing 26,574 pediatric patients.
Results indicate that the top 10% CHIC constituted 56.9% of total inpatient costs in 2010, for a total of $2.4 billion. In 2011 and 2012, however, 58% of those patients had no inpatient costs, although 27%, numbering slightly more than 7,000, racked up persistently high hospital charges.
Most associated with persistently high inpatient costs were chronic respiratory conditions, absence of surgery, and technological assistance. Further statistical modeling showed that the greatest likelihood of persistence, 65.3%, was found in CHIC with three or more hospitalizations in 2010 and a chronic respiratory condition.
“Most children with high children’s hospital inpatient costs in one year do not experience hospitalization in subsequent years,” study authors pointed out. “Interactions of hospital use and clinical characteristics may be helpful to determine which children will continue to experience high inpatient costs over time.”
According to a 2011 statistical brief from the federal Healthcare Cost and Utilization Project, children generally spend less time in the hospital -- an average 3.8 days -- and have about half the average costs than adults. The percentage of those stays being billed to Medicaid is increasing, going from 40% in 2000 to 49% in 2009.
Family Education on Impaired Patient Care Lowers CHF Readmissions
DETROIT – Taking some extra time to involve family members and educate them on how to care for someone with memory loss can pay off in significantly reduced hospital readmissions.
That’s according to a new study in the American Journal of Accountable Care. Henry Ford Hospital researchers tested the strategy with 489 patients in its congestive heart failure (CHF) unit and found that 30-day readmission rates dropped 30%, from 23% to 16%.
Lead author Mark Ketterer, PhD, called the strategy "astonishing simplistic but effective."
"Patients with memory loss often don't do well with taking their medication on time, renewing their medication and just coping in their day-to-day surroundings," Ketterer said in a Henry Ford press release. "If they're in a medical setting such as a nursing home, a nurse or other provider is able to monitor them and make sure they're doing these things reliably and consistently.
"Assigning a nurse to at-home patients is simply not feasible for manpower and cost reasons. We found that involving and educating the family about the forgetfulness we frequently see in patients and having them more involved in overseeing the care at home proved to be really successful in keeping patients from returning to the hospital."
Taking into account the cost of readmissions and the care associated with them, Ketterer theorized that nearly $180,000 a month could be saved for every 100 patients benefiting from effective involvement and education of family members.
Patients and families were deemed eligible for psychoeducation if the patient met any of the following criteria:
- was unable to repeat three simple nouns after the recruiter on the first try—assuming no environmental distractions and adequate hearing (immediate memory);
- was unable to name the current month, year, and building they were in (orientation);
- made two more mistakes on the clock-drawing test (executive function); or
- could not remember at least two of the three items after 3 to 5 minutes of distraction (short-term memory).
For patients displaying baseline cognitive impairment, the entire patient treatment team -- attending physician, resident, fellow, nursing, and case manager – was encouraged to convey concern about the patient’s likely difficulty adhering to the complex medication regimens. Patients and/or families then were approached with “Destigmatized Cognitive-Behavioral Psychoeducation,” which educated them about the frequency and nature of cognitive impairment and enlisted their help in managing care for the illness.
Better Nursing Translates Into Lower Mortality Risk After Surgery
PHILADELPHIA – Being recognized as a Magnet hospital with excellent nursing is an ego boost for hospital staff, but does that translate into better patient care?
A study published recently in JAMA Surgery suggests it does. University of Pennsylvania researchers found that patients undergoing surgery at hospitals recognized for nursing excellence and good nurse staffing have better outcomes at the same or lower costs than other hospitals.
"We found that patients treated in hospitals with better nursing had significantly lower death rates after surgery," explained lead author Jeffrey H. Silber, MD, PhD, director of the Center for Outcomes Research at The Children's Hospital of Philadelphia and senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Silber explained that the outcomes advantage for patients in Magnet hospitals was greater for all patients, but especially for those who were sicker and had more complicated cases.
This study included 25,752 elderly Medicare general surgery patients treated at focal hospitals – mean nurse-to-bed ratio, 1.51 -- and 62 882 patients treated at control hospitals – mean nurse-to-bed ratio of 0.69 -- during 2004-2006 in Illinois, New York, and Texas.
Results indicate that 30-day mortality in focal hospitals, which were larger and more teaching- and technology-intensive, was 4.8% compared to 5.8% in control hospitals. The cost per patient was similar, however, although the actual expenses at focal hospitals were slightly lower.
The greatest mortality benefit of 17.3% vs. 19.9 for focal and control hospitals, respectively, was for patients in the highest risk quintile, with a nonsignificant cost difference of $941 per patient. Results indicate that the greatest difference in value between focal and control hospitals appeared, however, in patients in the second-highest risk quintile, with mortality of 4.2% vs. 5.8%, with a nonsignificant cost difference of $862.
"A surprising finding was that better nurse staffing throughout the hospital does not have to be more costly,” Linda Aiken, PhD, RN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, pointed out in a University of Pennsylvania press release. “Indeed, we found that Magnet hospitals achieved lower mortality at the same or lower costs by admitting 40% fewer patients to intensive care units and shortening length of hospital stay.”
Upcoming Live Hospital [Webinars]
Transitional Planning Under New and Proposed CMS Guidelines
Live: February 17 Credits: 1.5 CCM & 1.5 CE
Restraint and Seclusion: The Most Problematic of All CMS Standards
Live: February 17 Credits: 1.5 CE
CMS Medical Records: What You Need to Know
Live: February 23 Credits: 1.5 CE
Give Falls the Slip: TJC & CMS Hospital CoPs & Standards
Live: February 29 Credits: 2 CE
Professionalism in Social Media: Guidelines for Healthcare Workers
Live: March 1 Credits: 2 CE
CMS & TJC Compliance Measures for the Case Manager’s Daily Practice
Live: March 2 Credits: 1.5 CCM & 1.5 CE
Grievances and Complaints: Compliance with CMS, TJC & DNV Standards
Live: March 7 Credits: 1.5 CE
Increasing Patient Satisfaction & HCAHPS Scores Through Digital Dashboarding
Live: March 8 Credits: 1 CE
Measuring Success: Does Your Case Management Department Make the Grade?
Live: March 9 Credits: 1.5 CCM & 1.5 CE
Hot Topics in Risk Management and Patient Safety
Live: March 15 Credits: 2 CE
Informed Consent: Meeting CMS, TJC, and DNV Requirements
Live: March 16 Credits: 2 CE
IV Medication & Blood Administration: Did Your Hospital get the Memo?
Live: March 17 Credits: 1.5 CE
Contracted Hospital Services: Certifying Compliance with CMS, TJC & DNV
Live: March 23 Credits: 2 CE
Clarifying the Confusing CMS Hospital Surgery, PACU, and Anesthesia Standards
Live: March 28 Credits: 2 CE
Patient Rights: Complying with the CMS Hospital CoPs
Live: March 30 Credits: 2 CE
