Hospital Acquired Conditions

(HACs)“Stop HACs, Keep Patients Safe”

James Pippim, MD, MPH, FACP, FCCP

None

Disclosures

Objectives

• Describe the burden of HACs

• Identify the risk factors for HACs

• Discuss evidence based guidelines used to prevent HACs

Hospitals in the US • American Hospital Association (2014)

– 5700 Hospitals 921K Beds 36M Admissions $ 829B Total Expenses

• Safest place to be for sick people– Around the clock access to skilled care teams– Continuous monitoring of pts vital signs– Checked on frequently by HC team

Sobering Reality• 3X as many people die due to medical errors in

our hospitals as die on our highways

• It would take 200 747 airplane crashes annually to equal the 100K hosp. preventable deaths

• Statements made about our hospitals– Best way to deal with them is to avoid them at all costs– Become a controlled beast as soon as you enter the ring

because no one can protect you except you

Why Are Hospitals So Unsafe?

• Hospitals starve, sleep deprive and spread infections among patients

• Med side effects, bed sores, broken bones, blood clots and loss of body parts

• Medical errors are the 3rd leading cause of death in the US after heart dx and cancer

“Stop The Hacks”

A colloquial and usually pejorative term used to refer to writers who are paid to write low quality rushed articles or books with short deadlines. (“Mercenaries” or “Pens for Hire”)

They were paid by the number of words in their articles or books so hacks had a reputation for quantity taking precedence over quality

“Stop HACs”

Current term used to describe providers who are paid to perform low quality services often with short deadlines. (“Hired Assassins” or “Stethoscopes for Hire”)

Paid by the number of procedures performed so HACs have a reputation for quantity taking precedence over quality

What Are HACs?1. Medical conditions or complications

2. Develops during a hospital stay

3. Was not present on admission

4. Preventable in most cases

80% of HACs are due to 1. CAUTI, CLABSI, VTE, VAP

2. Falls and Trauma, Pressure Ulcers

3. Obstetric Adverse Events, Surgical Site Infxns

4. Adverse Drug Events, 30-d Readmission Rates

Very Important HACs

1. High cost or high volume conditions or both

2. That resulted in an MS-DRG with a higher

payment when present as a 2ry diagnosis

3. That could reasonably have been prevented

through the application of EBM guidelines

4. Would no longer receive higher payment if

the condition was hospital acquired

DRA Section 5001(c) US DHHS 10/2008

1. Vascular Catheter-Associated Infection (CLABSI) 2. Manifestations of Poor Glycemic Control3. Surgical Site Infection (SSI) 4. Blood Incompatibility5. Pressure Ulcer Stages III and IV6. Falls and Trauma:7. Catheter-Associated Urinary Tract Infection (CAUTI)

8. Foreign Object Retained After Surgery9. Air Embolism

10. DVT and PE (TKR, HR)11. Iatrogenic Pneumothorax with Venous Catheterization

FYs 2014 and 2015 Categories

HAC Payment Provisions

Three Never Events1.Wrong Patient2.Wrong Body Part3.Wrong Procedure

How bad is the problem?• Total no. of HACs 4.1 Million (2012)

– 1 in 9 hospital admissions– 132 HACs per 1000 discharges– 560K fewer HACs, 15K fewer deaths and $4

Billion saved c/t 2010

• Top 5 HACs – ADE (34%), HAPU (28%), Others (19%)– CAUTI (8%) and Falls (6%)

Biofilm

US Acute Care HAIs-2011Type Of Infxn Estimated No Percentage

Pneumonia 157, 500 24.3%

Surgical Site 157, 500 24.3%

GI Infection 123, 000 19%

Urinary Tract 93, 300 14%

Primary BSI 71, 900 11%

722K HAIs occurred in US acute care hospitals in 201175K of these hosp. pts died annually from their HAIs $30B in excess cost every year

N Engl J Med March 27 2014; 370:1198-1208.

Risk Factors for HACsIntrinsic Risk Factors Extrinsic Risk Factors

Patient’s age Large city hospital

Patient’s weight Prolonged hospitalization

Patient’s gender Devices (CVC, UC, ETT, MV)

Underlying diseases or conditions Meds, Abx, Transfusions, TPN

Immune deficiency and organ failure Invasive procedures and major sx

Immobilization, Hosp. environment

CLABSIs

Risk Factors for CLABSIs

Intrinsic Risk Factors Extrinsic Risk Factors

Patient’s age Multiple CVCs or multilumen CVCs

Patient’s gender Heavy colonization at insertion site

Underlying diseases or conditions Prolonged hospitalization b4 CVC

CVC insertion in the ICU or ED

Femoral or IJ access site

Parenteral nutrition

CAUTIs

Risk Factors for CAUTIIntrinsic Risk Factors Extrinsic Risk Factors

Patient’s age Antimicrobial therapy

Patient’s gender Prolonged catheterization

Underlying diseases or conditions Other active sites of infection

Catheter inserted outside the OR

Rigorous monitoring of urine output

Improper positioning of drainage system

Risk Factors for HAPU

Risk Factors for Falls

1. Lower body weakness 2. Difficulties with gait and balance 3. Use of psychoactive medications 4. Postural dizziness 5. Poor vision 6. Problems with feet and/or shoes7. Hospital hazards

1. Before touching a patient2. Before clean/aseptic procedures3. After body fluid exposure/risk4. After touching a patient5. After touching patient’s surroundings

• Good Hand Hygiene by ALL providers

• Checklists to ensure consistent care

• Bundle up your approach to care

• Team up and communicate

• Be a role model/innovator

HAI Reduction

CAUTI Prevention

CAUTI Prevention

CAUTI Prevention

CAUTI Prevention• Insert catheters only for appropriate indications• Leave catheters in place only as long as needed• Ensure that only properly trained persons insert

and maintain catheters• Insert catheters using aseptic technique and

sterile equipment (acute care setting)• Following aseptic insertion, maintain a closed

drainage system• Maintain unobstructed urine flow• Hand hygiene and Standard (or appropriate

isolation) Precautions

At insertion 1.Checklist to ensure adherence to infxn prevention practices2.Hand hygiene before catheter insertion or manipulation3. Avoid the femoral vein4. Use an all-inclusive catheter cart or kit.5. Use maximal sterile barrier precautions during insertion6. Use a chlorhexidine-based antiseptic for skin preparationAfter insertion 1. Disinfect catheter hubs, needleless connectors & injection ports before accessing the catheter2. Remove nonessential catheters3. CHG baths/dressing and antimicrobial catheters

CLABSI Prevention

SSI: Effective interventions

1. Administer antimicrobial prophylaxis

2. Do not remove hair at the operative site unless the presence of hair will interfere with the operation

3. Do not use razors

4. Control blood glucose level during the immediate post op period for pts undergoing cardiac surgery

5. Measure and provide feedback to providers on their compliance rates with the above process measures

VAP: Effective interventions

1.Implement policies and practices for disinfection, sterilization & maintenance of resp. equipment

2. Provide easy access to noninvasive ventilation equipment & use weaning protocols.

3. Ensure that pts are maintained in a semi-recumbent position

4. Perform antiseptic oral care according to product guidelines

2010 - That Was Then

2014 - This Is Now

1) Foreign Object Retained After Surgery 2) Air Embolism 3) Blood Incompatibility 4) Stage III and IV Pressure Ulcers 5) Falls and Trauma Fractures, Dislocations, Intracranial Injuries, Burns Crush Injuries, Electric Shock

2014 HACs-This Is Now

6) Manifestations of Poor Glycemic Control DKA, NKHC, Hypoglycemia, 2ry DM + KA, 2ry DM + Osm. 7) Catheter-Associated Urinary Tract Infection (UTI) 8) Vascular Catheter-Associated Infection 9) Surgical Site Infection CABG, CEID, Bariatric Surgery, Orthopedic Procedures 10) DVT/PE TKR, Hip Replacement

AHRQ* PSI 90 Measure Score 1-10PSI 3 Pressure ulcer ratePSI 6 Iatrogenic pneumothorax ratePSI 7 CVC related blood stream infection ratePSI 8 Postoperative hip fracture ratePSI 12 Postoperative PE or DVTPSI 13 Postoperative sepsis ratePSI 14 Wound dehiscence ratePSI 15 Accidental puncture and laceration rate

Domain 1

CDC NHSN Measures Average Score 1-10CLABSI SIR rate 1-10CAUTI SIR rate 1-10Performance Period (7/1/2011– 6/30/2013)

Future Measures For FY2016SSI ColonSSI Abdominal Hysterectomy

Future Measures For FY2017MRSACDI

Domain 2

• Common, costly and frequently fatal• 10 conditions account for 80% of HACs• Extrinsic risks factors maybe modifiable• Evidence based preventive guidelines may help

decrease its incidence and impact• Adhere to EBM, Bundles of care, Checklists and

Discharge pts from high risk areas

Summary

I LOVE sick peoplebut I don’t like signingDeath Certificate