How are "never events" affecting your practice?

Roy Fokker, BSN, RN · Sep 15, 2008

I for one, think this guy is on track:

It is unfortunate that someone so misinformed about the effects of "never events" on the practice and accessibility to medical care is allowed to publish an article like this. It is even more unfortunate that so many of the members of the general public support Ms. Suchetka's ramblings.
First of all, look at the contradictions contained within this article itself. She quotes someone from "SHIC" as saying that "If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented." Wait a second. "Vast majority?" I thought that these were "never events." Shouldn't Captain Obvious have stated that the events would "never" happen if the policies were followed?
Medicare calls the "errors" "reasonably preventable." If they are "never events," shouldn't they be called "entirely preventable"? If they are "never events" then I want to see the people who came up with that term treat patients for a year and show me their results in preventing them.
There are other misstatements. Realitynurse states that "C. diff is a medical mistake." Uninformed and untrue statement. C. diff is an organism that lives and grows just like every other organism on this planet. Antibiotic use may increase the prevalence of C. diff, but antibiotic use does not "cause" C. diff. Your statement is akin to saying "mosquitoes are a mistake" or "uninformed nurses are a mistake."
Why has C. difficile become so ominous? Up to 20% of people prescribed clindamycin can develop C. difficile. What exactly should we do to make sure that not one single patient ever develops a C. difficile infection? Go on. I want all you smart people to tell me. Stop prescribing all antibiotics? Sounds like a plan. Then Medicare will deem all the other infections as "never events," too.
If any of the people reading this column want to avoid never events, here's how to do it: Don't go to doctors and stay away from hospitals. That's right. Boycott us. If you want to create a manual on how to provide perfect medical care while you're treating yourself for a ruptured appendix, I'd be happy to read it.
Ms. Suchetka is right that these Medicare rules will affect all of us, but she has the wrong reasoning. They will affect all of you that develop these conditions because physicians and hospitals will avoid you like the plague. If you are prone to falling, good luck finding a doctor to treat you. Immunocompromised and likely to develop infections? Better read up on those medical journals. You'll be treating yourself soon.
"Medicaid expenses could drop"? Get a clue. They won't drop, they'll increase. No one will accept Medicaid patients with predispositions to these conditions and the patients will end up in the emergency department where the care is really inexpensive. Maybe Medicaid should focus its efforts on reigning in those that misuse their access to health care in order to score some pain meds. That would save a lot more money than this all this hogwash about those things that are and are not preventable.
Hospitals are "get[ting] the message" alright. They're closing. Doctors are getting the message, too. Fewer and fewer specialists are treating patients from emergency departments because they don't want to deal with people who expect perfection and who then try to sue when they don't get it.
When your local hospital closes down or when the wait for care is so long that you or a loved one develop a bad outcome because of it, you can thank people like Ms. Suchetka for putting pablum to paper.

Read the entire post.

It's certainly interesting. The whole problem with CMS' theory is the determination on whether a "never event" has occurred is retrospective, not prospective. By focusing once more on outcomes rather than process, CMS can once again pass the buck and tidy up their image by saying "patient safety!" and leave the entire dirty mess at the feet of health care providers.

cheers,

november17, ASN, RN · Sep 15, 2008

Thank you for the post and I agree with it 100% (comin from the trenches of nursing care!).

It is really sad that we will be turning people away from our unit. Amazingly, the vast majority will in fact be medicare (i.e. ER patients). Seriously, thanks for posting that because you opened my eyes a little bit to what the heck is going on here and seeing the bigger picture.

mama_d, BSN, RN · Sep 15, 2008

I feel like my hands are tied already in some cases, b/c we started implementing protocols the beginning of this year to address what was coming down the pipeline.

The most frustrating is when we have an incontinent patient at high risk of skin breakdown due to decreased mobility (or who refuses to stay off of their back). What costs more, an infection from a Foley or a hospital acquired pressure ulcer from skin breakdown due to constant incontinence? Our care plans for high risk skin patients specifically state to consider the use of urinary or fecal drainage devices...I'm sure that'll be changing soon.

We even had a patient recently whose daughter would stick her unwashed, ungloved finger into a surgical site to "measure" how well it was healing...patient presented with it infected, after we had sent her home with a clean incision. How does medicare/medicaid view that kind of familial "intervention"?

Does anyone know if the patient's refusal to allow interventions to prevent these "never occurances" changes reimbursement, or is my facility stuck paying for them? Or is it just one more thing to impact the budget, which they keep trying to trim by cutting down on our raises and benefits....

Seems like nursing is just becoming a minefield of Catch-22's, all designed to actually hinder the healing process.

Roy Fokker, BSN, RN · Sep 15, 2008

What costs more, an infection from a Foley or a hospital acquired pressure ulcer from skin breakdown due to constant incontinence?

According to CMS, it doesn't matter. They are both "never events" - you won't get paid either way...

cheers,

JRD2002 · Sep 15, 2008

Very funny video link

DusktilDawn · Sep 15, 2008

Do I think hospitals should be doing more to prevent adverse outcomes and reduce the risk of some of these so-called "never events," absolutely. But this is the entirely wrong way to do it.

I think it will hinder and cost health care MORE in the long run. I think that patients will be denied care or have an increasingly difficult time accessing care if they fall into a high risk group for developing complications that fall under the category of "never events."

I think both doctors and nurses will be even more scrutinized and blamed when these "never events" occur. This is going to effect how both professions practice. Doctors will be reluctant to take on patients that are high risk, they will be reluctant to treat these patients, and they will be reluctant to perform any invasive procedures/surgeries on these patients. Since these are complications that are being trotted out as "never events," I see an increase in malpractice insurance, claims, and lawsuits. After all, these things should "never" happen. I see LTC or assisted care residents being denied access to acute care. I see the facilities that care for these residents becoming increasingly fewer in number. Nurses, who already shoulder the blame in a system that is designed more to impede them more than it is to enable them to provide quality care to patients, are going to be in a worse position than they are in now. It seems to be the trend that the forms "inspired" by accreditation agencies like JCAHO and organizations like CMS have become more important than the patients. I see this trend becoming worse. Nurses had better become experts in CYA documentation.

I see health care facilities under reporting and manipulating the numbers of these "never events," after all they are "never" suppose to happen. They're pretty good already at denying glaringly obvious problems and/or blaming nurses when they do occur, they're going get even better. I see this a further hindering for nurses when it comes to patient advocacy.

I see the situation like the OP described, floors where patients are refused admission to. I see units refusing patient transfers because although the patient needs the private room available, that unit doesn't want to have to have the cost of taking care of that C-diff patient on their budget. I see them not accepting that admission from LTC because who knows if they already have MRSA or VRE.

All CMS is doing is professing and posing to the very public they're screwing about how they have their best interest at heart. Gee, we all know it's not the public who's best interest is what they have at heart.

lizva101 · Sep 15, 2008

Oh, just had an entire post lost.

So, very interesting thread. Thank you.

Prevention.

UTI's, if sterile technique and organism resistant catheters are used, how can medicare not pay for UTIs. And, should ALL patients be screened for UTI as policy in ED? That would be a good QI policy.

Response to Medicare's demands...

I think it is quite interesting turn of events.

If the hospital were to dedicate a unit to pts with risk of skin ulcers, then that unit would have to have ancilliary staff dedicated to 2 tasks: repositioning EVERY 2 hours and Toileting every 2hours on every patient and proper skincare. Then , I would think that medicare would have to COVER the cost of the extra staff if they are demanding pts to be free from skin ulcers ect.

2nd unit --- dedicated to only isolation pts. I do think this is a good idea. Perhaps the hospital could make the staff more comfortable isolation protective gear! and then add that to the bill for medicare. If I wasn't allergic/sensitive to those yellow gowns and suffocating mouth gear I would go for it. I think tThey would be good for the patients, both for better care and morale. These new standards from medicare might give a lot of leverage to the hospital to start billing for preventative measures taken, i.e. more STAFF, new units, ect.... And I think it would be good for these patients to be better treated, a staff nurse simply can not give skin care and all the preventative measures necessary to prevent skin breakdown on every patient each day. And nursing assistants can not truly document effective preventive measures either as they are constantly being pulled in many directions and could not document effectively even if they were able to provide the care.

Screening for skin breakdown pts could start in the ED (i.e. braden scale) and those who score could be admitted to the new unit. And their admission could be expediated. I work in the ED, and they say after 4 hours, skin on a normal young patient begins to be at risk for skin breakdown/pressure sores. And in the ED, pts can be on the stretcher for a very long time.

I say, administrators -- take a good look at these new demands and face 'em head on. Fight a good fight.

OC_An Khe · Sep 15, 2008

There is no easy answer to this. The private MDs will continue to get paid by medicare (My understanding at this time) for the time they spend caring for patients wiith never events. It is just the facilities that won't be reimbursed. My gut feeling is that the Never events will expand in numbers and those facilities that don't meet standards of adequate staffing will begin to fail. Remember all this information is going/ already is posted on government web sites. Consumers as they become more computer literate will begin choosing their health care facilities by these quality ratings. Of course in the more rural areas where there is only one choice this won't help much.

Ivanna_Nurse, BSN, RN · Sep 15, 2008

Yeah, so.. we have a policy. I think in there it says something along the lines of apologizing to the patient, explaining what occured and covering the costs associated with whatever happened. Sigh. ~Ivanna

RNperdiem, RN · Sep 15, 2008

Do the patients have any responsibilities too?

It seems that as hospitals, doctors and nurses are being given more responsibility and accountability, the patients are having less.

iluvivt, BSN, RN · Sep 16, 2008

Do not forget that more never events may be added to the list. While I agree we can do better in some of these situations I disagree with how it is being handled as well. Most of my experience will be with the CRBSI (catheter-related bloodstream infection). Get this ....new research is finding that no matter how well you scrub or how many times before you place a PICC or CVC there may be resident bacteria in the deep skin layers that may lead to infection. So how are we going to fight nature and why should the patient and the nursing and medical profession suffer for that. How come you are seperating your medical and surgical patients. I know the answer but some will say if you are following standard precautions it should not make a difference!!!!!