By Doug Kaufman, MD Consult, September 29, 2008

On October 1, 2008, Medicare insurance will no longer reimburse hospitals for what Medicare deems 11 secondary conditions seen as "preventable complications of medical care."

"It certainly shines a bright light on something that we have been doing, but we all need to be doing more," said Jonathan Gottlieb, MD, vice president and chief medical officer at Barnes-Jewish Hospital in St. Louis. "I think it will have a beneficial impact on patients."

While this will affect the way hospitals care for patients and conduct business, most hospitals should be prepared for the change.

"That''s not a surprise to us at all," Dr Gottlieb said. "This goes back a couple of years. ... The AHRQ [Agency for Healthcare Research and Quality] and others have listed events that they believe, and we believe, are preventable."

The following conditions, if not present at the time of hospital admission, "will no longer be taken into account in calculating payments to hospitals," according to information available on the Web site of the Joint Commission on Accreditation of Healthcare Organizations. The conditions are:

1. Foreign Object Retained After Surgery (750 cases nationally in 2007)
2. Air Embolism (57 cases)
3. Blood Incompatibility (24 cases)
4. Stage III and IV Pressure Ulcers (257,412 cases)
5. Falls and Trauma (193,566 cases)
6. Catheter-Associated Urinary Tract Infection (12,815 cases)
7. Vascular Catheter–Associated Infection (29,536 cases)
8. Surgical-Site Infection: Mediastinitis After Coronary Artery Bypass Graft (69 cases)
9. Surgical-Site Infections Following Elective Procedures (number of cases unavailable)
10. Glycemic Control Issues Such as Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Diabetic Coma, and Hypoglycemic Coma (16,060 cases)
11. Deep Vein Thrombosis/Pulmonary Embolism (140,010 cases)

Infection prevention is high on every hospital''s list, Dr Gottlieb said.

"We''ve been concerned about it for many years," he said. "We''ve learned, through the years, as we''ve implemented different processes. Not just policies, but really changing the way we do things to make our care more reliable. So, for example, with central catheters—intravenous catheters that everyone recognizes can become infected and lead to patient complications and even death—we''ve really taken the step-wise approach probably over the last 8 to 10 years."

Barnes-Jewish has changed the antiseptic used with the catheters and also provides educational programs for the people putting in the catheters and those taking care of the catheters.

"Both doctors and nurses have important roles in preventing infection," said Dr Gottlieb, a pulmonologist who remains an attending physician in the medical intensice care unit on a rotating basis.

The hospital has established a system where caregivers can see catheter infection rates in "almost real time," he said. "... It''s much easier to see the results of your efforts."

Barnes-Jewish is seeking to "take it to the next level" by examining the entire process for putting in central catheters.

"Who decides," Dr Gottlieb said, "how do you pick the right catheter, which are the appropriate patients, how can we standardize the equipment so the clinician finds exactly what he or she expects?"

In addition to the catheter education program for every resident and intern involved with catheters, the hospital also has a simulation program in place.

"This past July, we had more than a hundred of our incoming residents not only get the educational session, but they then went through this 6-stage simulation and then were assessed on their ability to put in a catheter," he said. "The idea is we''re making a more reliable environment for our patients who need these catheters."

It''s too early to know whether this last effort has made a direct impact, Dr Gottlieb said, but catheter infection rates at the hospital continue to fall.

"I really think we, as does everyone else, need to build in the extremely high degree of reliability that we''re capable of, and that our patients expect," he said.

While none of the 11 safety measures caught Barnes-Jewish staff unaware, medication errors are "potentially the most complex because there are so many steps," Dr Gottlieb said, "from prescribing to dispensing to administering."

The hospital, consistently chosen one of the top 10 hospitals in the United States, is implementing a computer-entry system to reduce medication errors. Part of this includes bar-code identification for all patients, with medication needs and doses appearing on a computer screen after the patient''s wristband bar code is scanned.

"I think a little more than 5% of institutions have comprehensive computerized physician order entry, even though everybody talks about it," he said. "So over the next several months, we will join those ranks, as will many other places. But I think that is absolutely an essential piece to building in the reliability for an incredibly complex process."

The computerized physician order entry, which should be heavily in use at Barnes-Jewish within 12 to 18 months, will help medical professionals ensure the dose is appropriate and will alert them to drug interactions.

"All those manual things that we rely on perfect people to do," he said. "But of course, none of us are perfect. It also, by the way, takes the whole handwriting issue out of the equation. Which again is no small issue."

The safety measures plan as presented by Medicare is "an imperfect system right now," Dr Gottlieb said. "For example, there''s a lot of discussion about making venous thromboembolism blood clots one of the ''never events'' that won''t be reimbursed for. I think we have to be really careful about being wise in the things we select. What I mean by that is, many blood clots are just not preventable. So the burden should be on making sure health care institutions do absolutely everything appropriate to prevent them. We must be held accountable for that. Having done that, if a blood clot should occur, that''s a completely different story."

Dr Gottlieb expects some flexibility on the part of Medicare.

"I think this will be a dialog, just as many of the core measures have been modified," he said. "Some of them have been modified too slowly for some. But clearly it won''t be perfect right out of the gate. There''ll be some room for dialog and modification. But the direction is absolutely the right direction. The public wants it, the patients expect it, and hospitals and health care providers want to do the right thing in a reliable way."

The original safety measure for treating community-acquired pneumonia, for example, called for antibiotic treatment within 4 hours, Dr Gottlieb said.

"That was a very contentious requirement that I don''t believe, and many others don''t believe, was supported by the evidence," he said. "So, they did modify that."

Many of the safety-measure recommendations are pretty basic expectations, he said.

"BJC, across the entire system, is not looking so much at the payment aspect, the CMS aspect, but more on really avoiding preventable harm," he said. "... We''re embarking on ''preventable harm'' teams across the system."

They will be implemented locally, but teams will share their "best practice" ideas and procedures across the system concerning such problems as pressure ulcers, falls, medication errors, hospital-acquired infection, and more.

Concern has been voiced that hospitals may find a way to pass the costs no longer covered by Medicare along to patients. That shouldn''t be a concern, Dr Gottlieb said.

"If we have made an error and a patient has suffered, I don''t think any patient expects to pay for that," he said.

Preparation and attention to detail are essential cores for reducing preventable errors.

"It takes a commitment of an interdisciplinary team of people who are close to patients—front-line doctors, nurses, pharmacists, therapists—coming up with potential solutions supported by the very top leadership," he said. "You absolutely need to get leadership''s commitment, but then the work needs to be done by the people who are ... taking care of patients involved in these processes. They''re really the ones who can see the opportunities to build reliability and error prevention into the system."

As these changes take effect, Dr Gottlieb urges hospitals to remain vigilant when it comes to distinguishing between hospital-caused errors and being held accountable for unavoidable bad outcomes where fault can''t and shouldn''t be attached.

"That will always be a tension," he said. "Providers need to be outspoken and engage Medicare in the dialogue, so we can focus on the things where we can actually have an impact, and improve care for our patients. As opposed to being distracted by what we may or may not get paid for."