[Kelly_the_Great]

CMS made an announcement April 14th to propose an expansion to the “Never Events” list, which include the following:

· Surgical site infections following certain elective procedures
· Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
· Extreme blood sugar derangement
· Iatrogenic pneumothorax (collapse of the lung)
· Delirium
· Ventilator-associated pneumonia
· Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
· Staphylococcus aureus septicemia (bloodstream infection)
· Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

Two of the items that I see right off the bat that seem pretty arbitrary to me are: extreme blood sugar derangement and delirium. While regrettable when they occur and hopefully soon corrected, they are relatively common events when persons are seriously ill.

Additionally, c-diff is a significant issue. Two cases I only recently reviewed whereby patients had negative stool samples and yet had positive findings with sigmoidoscopy (not a cheap procedure to perform). Thus, rarely performed first, thus making it hard to determine time of onset.

If adopted, decrease in reimbursement would take effect as of October 1, 2008 (6 months away). This is of great concern! "Present on Admission" has been a real challenge for us. Most importantly, I'm afraid the inclusion of some of the proposed items may ultimately cause patient suffering either in reluctance by providers to perform certain task, i.e. central line insertion, due to fear of complications (pneumothorax, central line infections, etc.) or the outright refusal of patients for transfer who are high risk for developing complications, i.e. 87 y/o female with (R) hip fx may develop delirium or 33 y/o IV drug user with ARDS needing PEEP, showing s/sx of sepsis and fluctuating BS levels, for example.

CMS will be accepting comments on the proposed rule through June 13th and will respond to comments in a final rule to be issued on or before August 1, 2008.

I urge everyone to write them with your thoughts and suggestions.

P.S. Here's a link to a pdf document you can save to distribute to your colleagues from hcPro.

[NRSKarenRN]

CMS PROPOSES TO EXPAND QUALITY PROGRAM FOR HOSPITAL INPATIENT SERVICES IN FY 2009

...CMS is proposing to expand the list of conditions which are reasonably preventable through proper care and for which Medicare will no longer pay at a higher rate if the patient acquires them during a hospital stay. In addition, CMS is adding 43 new quality measures for which hospitals will have to report data in order to receive the full annual payment update for their services....

.. The proposed regulation builds on efforts across Medicare to transform the program to a prudent purchaser of health care services, paying based on quality of care, not just quantity of services...

Numerous studies have documented the detrimental effects on patients and their loved ones and the increased costs of health care services resulting from a preventable patient’s injury or condition acquired due to hospital errors. These can include “Never Events,” those events that never should occur, like amputation of the wrong limb or transfusing patients with the wrong blood type. CMS is working with the National Quality Forum (NQF), a national organization working to promote patient safety and improve hospital care, on ways to reduce or eliminate 28 Never Events identified by NQF...

...In its 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) concluded that medical errors, particularly hospital-acquired conditions (HACs), may be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion. In 2000, the Centers for Disease Control and Prevention (CDC), estimated that hospital-acquired infections added nearly $5 billion to hospital costs. At the same time, a 2007 survey by the Leapfrog Group of more than 1,200 hospitals found that 87 percent did not follow recommendations to prevent many of the most common hospital-acquired conditions....

..In proposing to require hospitals to report on readmissions, CMS notes that almost 18 percent of Medicare patients are readmitted to the hospital within 30 days of discharge, potentially exposing the patients and their families to significant additional suffering. Taken together with the patient satisfaction information recently reported on Hospital Compare web site that shows the effectiveness of nurse and physician communication with the patient, including discharge planning, the building blocks for monitoring and improving the entire episode of care will be available. The impact on taxpayers is also significant. According to the Medicare Payment Advisory Commission (MedPAC), readmissions cost the program $15 billion annually, with $12 billion of those costs potentially preventable.

[Indy]

Well I'm gonna show this to my boss. Maybe then the P&T committee (whatever that stands for, I call it the powers that be committee) will decide on a blood sugar control protocol that everyone has to have in icu regardless of who their doctor is or whether or not he's changed his tampon recently.

Yep. And so delerium has to be an admitting diagnosis now. Got it.

[TiredMD]

There's a saying among surgeons: if you're not having complications, you're not operating enough.

Complications are a reality of medical practice. Bad things sometimes happen despite our best efforts. That's why complications are not, in and of themselves, grounds for malpractice suits. That's why we warn patients of potential complications during informed consent.

Pretending like an iatrogenic pneumo or line sepsis should never happen is ridiculous.

This is just a bunch more reasons I won't be accepting Medicare/Medicaid patients once I'm in private practice.

[Mijourney]

To get to the point where medical errors and waste are severely reduced and see savings in the governmental programs, I feel you need highly skilled and trained practitioners at the bedside. You also need reasonable staffing to take care of complex needs. Has the government shown a williness to spend the money required for this? Not so far.

[CseMgr1]

Im just thankful that I don't have to deal with the lunacy of CMS and JCAHO anymore.

"And that's all I have to say about that". --Forrest Gump

[Kelly_the_Great]

Unfortunately, CseMgr1, I feel all this is a slippery slope that'll probably eventually slide into other fields of healthcare though...

[traumaRUs]

Yes, we are already seeing side effects from this nonsense. The added expense of testing everyone for VRE and MRSA for one thing. Its only going to get worse, unfortunately.

[RN1980]

said it before and i'll state it again, just a bunch of smoke and mirrors...it's all about saving money not ablout saving patients. agian i claim if the gov't is so concerned about patient saftey and wellfare, then they should take a stance on proper and safe nurse and staff to patient ratio's. that is where the meat of the matter is concerning your everyday floor pounder nurse...

[Kelly_the_Great]

Oh yeah, RN1980. If it was truly about patient safety, they'd be penalizing doctors' (no offense, TiredMD) reimbursement vs. the hospitals.

See the hospitals have a larger bill than do the doctors. That's what it's all about...$$$$$$ This is just cost containment pure & simple guised as patient safety, which we all want ~ so it's an easier pill to swallow, so to speak.

Most of these so called "events" are due to doctor action, i.e. over prescribing antbx ~ hence, c-diff or pneumothroax ~ if it's occuring in the hospital??? just about the only cause is physician technique with central line insertion.

Don't get me wrong, I'm not doctor bashing, I'm just callin' like I see it. Like I said, this is a slippery slope, I can totally envision them saying, "A nurse had to stick you 4 times and a vein was blown in the process? Oh, we're not going to pay for IV meds then." Makes about as much sense, you know? There are risk involved in just about everything we do.

Hell, even when you think about healthcare acquired infections, you can use the strictist of aseptic technique, 100% hand washing compliance, etc. but what do you do about patients voiding, not washing their hands and then touching their CV port?

Additionally, RN1980, when they penalize hospitals, what happens? They ALWAYS cut nursing staff ~ so much for appropriate ratios, skill mix, compliance, etc.!!!!

I'm waiting for the day they just say, "A sick patient should NEVER get sick or sicker."

Anyways, I've wrote my state's nurses' association of which I'm a member in hopes they might advocate for the patients with a unified voice. I also wrote my congressman and senators.

I'm trying to think of a "diplomatic" letter to send to a few letters to the editor. Hard to develop right now ~ feelings are too riled up now!