SSI Guidelines – What’s New and What’s Not


In May of this year, the CDC published an update on Surgical Site Infections (SSI) Guidelines 1. This followed a 6-year partnership with the Healthcare Infection Control Practices Advisory Committee (HICPAC), whose clinical experts provided feedback and input. Although it was the first update on these guidelines by the CDC in nearly 18 years, and greatly anticipated by clinicians and industry alike, there was minimal fanfare surrounding it.

Some experts have responded, but awareness surrounding these changes is still relatively low, especially considering that SSI is touted as the most costly hospital-acquired infection and the number of surgical procedures in the U.S. continues to rise 2,1. This post will outline what’s changed, what hasn’t, and provide a short list of other available options.

You may recall from our earlier blog post, “SSIs and Post-Op Dressings: What’s Missing?”, the prevalence as well as the clinical and financial impact of SSIs to patients and hospitals is very significant. Therefore, implementation of the latest evidence-based guidelines to reduce this risk are vital to improving outcomes and reducing associated penalties to hospitals.

What’s New or Changed?
Most notably, a new section on prosthetic joint arthroplasty is included and likely related to the significant financial burden associated with these surgeries. SSIs are known to cost up to $26,000 (in 2002 dollars), but those involving an implant can exceed $90,0001!
Remaining changes impact recommendations across the perioperative setting 1:

  • Parenteral Antimicrobial Prophylaxis
  • Nonparenteral Antimicrobial Prophylaxis
  • Glycemic Control
  • Normothermia
  • Oxygenation
  • Antiseptic Prophylaxis
  • Transfusion of Blood Products

What’s Remained the Same?
The updated CDC guideline leaves unchanged several of the original recommendations. This is reflective of the fact that 1999 guidelines were primarily based on expert opinion and points to the outstanding lack of evidence in these areas. More than half of the statements (25 of 42) are classified as “No recommendation/unresolved issue” 3.

What other SSI Guidelines Exist?
Updated guidelines have been published in recent years by groups due to the availability of new evidence and a need to summarize the most pertinent topics:

  • American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update 4
  • “Global Guidelines for the Prevention of Surgical Site Infection” by the World Health Organization (WHO) 5

Other peer-reviewed journal articles exist detailing practical strategies that can be championed by healthcare practitioners. One favorite is the 2014 update to the SHEA/IDSA practice recommendation by Dr. Anderson et al 1.

Join us for the next Eloquest Healthcare Blog where the first part of a 2-part series on kits will be featured, discussing the benefits of how kit components and configuration can improve adherence to procedure protocol thereby improving patient outcomes.

References

  1. Healthcare Infection Control Practices Advisory Committee. The Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg published online May 2017. Doi:10.1001/jamasurg.2017.0904.
  2. Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infection sin acute care hospitals: 2014 update. Infect Control Hosp Epdemiol. 2014;35:605-27.
  3. Preas MA, O’Hara L, Thom K. 2017 HICPAC-CDC Guideline for Prevention of Surgical Site Infection: What the infection preventionist needs to know. Prevention Strategist. https://apic.org/Resource_/TinyMceFileManager/Periodical_images/API-Q0414_L_SSI_Guidelines_Final.pdf. Accessed online August 25, 2017
  4. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;1:59-74.
  5. Allegranzi B, Zayed B, Bischoff P et al. New WHO Recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet. 2016;16e288-303.

Hospital-Acquired Conditions (HAC) Reduction Program

Our last blog provided some background on the READMISSIONS REDUCTION PROGRAM —a three-year rolling process of reporting all-cause readmissions within 30 days of discharge, along with potential penalties.1  Today, we’ll look at the third program established by the Affordable Care Act (ACA): the HOSPITAL-ACQUIRED CONDITIONS (HAC) REDUCTION PROGRAM.

HAC REDUCTION PROGRAM allows the Centers for Medicare & Medicaid Services (CMS) to reduce payments by 1% to hospitals in the worst-performing quartile.2 The CMS reduces payments for specific safety issues and hospital-acquired infections3

  • CAUTI | Catheter Associated Urinary Tract Infection
  • CLABSI | Central Line Associated Bloodstream Infection
  • SSI | Surgical Site Infection
    • Abdominal hysterectomy
    • Colon surgeries
  • MRSA | Methicillin-Resistant Staphylococcus Aureus Bacteremia
  • CDI | Clostridium Difficile Infection

HACs are acquired by patients while receiving care and represent the most frequent adverse event affecting patient safety worldwide.4 For FY 2017, CMS estimated that overall payments to 769 hospitals would drop by roughly $430 MILLION.5

There are two domains associated with the HAC REDUCTION PROGRAM.3:

DOMAIN 1 is based on Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 90 Composite Component Measures and provides an overview of hospital-level quality as it relates to a set of potentially preventable hospital-related events associated with harmful outcomes for patients.6 It is weighted 15%.4

DOMAIN 2 includes standardized infection ratios (SIRs) calculated by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) Measures.4 It is weighted 85%.4

Domain 1 is a weighted average of the 
risk- and reliability-adjusted versions of:

  • Pressure Ulcer Rate
  • Iatrogenic Pneumothorax Rate
  • In-Hospital Fall with Hip Fracture Rate
  • Perioperative Hemorrhage or Hematoma Rate
  • Postoperative Acute Kidney Injury Rate
  • Postoperative Respiratory Failure Rate
  • Perioperative Pulmonary Embolism (PE) or
  • Deep Vein Thrombosis (DVT) Rate
  • Postoperative Sepsis Rate
  • Postoperative Wound Dehiscence Rate
  • Unrecognized Abdominopelvic Accidental
    Puncture Laceration Rate

Domain 2 is Center for Disease Control’s (CDC) calculated standardized infection ratios (SIRs) for the CLABSI, CAUTI, and SSI measures. SIRs are ratios of observed-to-predicted numbers of HAIs. The CLABSI, CAUTI, and SSI measures are risk-adjusted at the hospital level and patient-care unit level:

  • CAUTI
  • CLABSI
  • SSI
  • Abdominal hysterectomy
  • Colon surgeries
  • MRSA Bacteremia
  • CDI

If you’ve been following our blog, you’ll probably remember that measures from Domain 2, which make up 85% of the weighting, are penalized in multiple programs—here, in the HAC Reduction Program as well as in the Value-Based Purchasing Program (VBP).

What’s the impact? Consider an average 300-bed Community Hospital with 48% of their patients being Medicare beneficiaries. If they have an inpatient Medicare revenue of $26,000,000 and received a $20,000 payment reduction for a condition/diagnosis, their 1% penalty reduction would be $200. That same reduction would be applied to EVERY inpatient Medicare claim submitted during the fiscal year and could result in a penalty of $260,000.

According to the CMS, there’s good news—improvements are being made. Across the last three fiscal years, 2015, 2016, and 2017, the average performance across eligible hospitals improved for the mean Catheter-Associated Urinary Tract Infection (CAUTI) standardized infection ratio (SIR) and the mean SIR decreased from 1.12 in FY 2015 and 1.17 in FY 2016 to 0.91 in FY 2017.7

If you’d like a comprehensive overview of the Affordable Care Act as featured in our last 4 blogs, click here to download the “True Transparency in the Cost of Care” infographic.

Come back next time when we review some of the latest clinical evidence on CAUTI risk reduction presented at the APIC Annual Conference 2017.

Minimizing infection risk is an essential part of optimizing “The Triple Aim” of the Affordable Care Act. Eloquest Healthcare is committed to providing solutions that can help you reduce risk of conditions like a CAUTI, CLABSI, or SSI.

References

  1. Understanding the Hospital Readmissions Reduction Program. The Lake Superior Quality Innovation Network, Centers for Medicare & Medicaid Services Quality Improvement Organization Program. https://www.stratishealth.org/documents/Readmissions_Reduction_Fact_Sheet.pdf.  Published November 2014. Accessed January 16, 2017.

  2. Hospital-Acquired Condition Reduction Program (HACRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html. Accessed January 16, 2017.

  3. FY 2017 HACRP Key Dates Matrix. Hospital-Acquired Condition Reduction Program (HACRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html. Accessed January 16, 2017.

  4. Health care-associated infections fact sheet. World Health Organization. http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf. Accessed March 30, 2017.

  5. Haefner M. 769 hospitals see medicare payments cut over high HAC rates: 7 things to know. http://www.beckershospitalreview.com/quality/769-hospitals-see-medicare-payments-cut-over-high-hac-rates-7-things-to-know.html. Published December 22, 2016. Accessed January 16, 2017

  6. PSI 90 Fact Sheet. AHRQ Quality Indicators. Agency for Healthcare Research and Quality. https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf. Published FY 2016. Accessed March 30, 2017.

  7. FY 2017 HACRP Fact Sheet. Hospital-Acquired Condition Reduction Program (HACRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/HAC-reduction-program.html. Accessed March 30, 2017.

Value-Based Purchasing Program

Our last post provided an overview of 3 programs created by the Affordable Care Act (ACA) to improve care, healthy people and communities, and affordable care.1 This post will focus on the Value-Based Purchasing Program.

The VALUE-BASED PURCHASING PROGRAM (VBP) is a performance-based payment strategy that links financial incentives to acute-care hospitals’ performance on a defined set of measure domains (categories) including2 :

  • CLINICAL CARE
  • EXPERIENCE OF CARE
  • SAFETY
  • EFFICIENCY/COST REDUCTION

NOTE: In fiscal year (FY) 2019, the CAUTI and CLABSI measures in the safety domain will expand beyond the ICU to “select wards” (ie, Medical/Surgical Units, etc.)

VBP is the only program established by the ACA that can reward or penalize a hospital for the quality of care they provide to Medicare beneficiaries.3 The Centers for Medicare & Medicaid Services (CMS) imposed a 2% reduction to base Diagnosis-Related Group DRG payments to create a pool for bonuses to be paid. In 2017, the payment increases added up to about $1.8 billion.3

  • the quality of care provided to Medicare patients
  • how closely best clinical practices are followed
  • how well hospitals enhance patients’ experiences of care during hospital stay

Each hospital earns 2 scores on each measure—one for achievement and one for improvement.3 The final score awarded to a hospital for each measure is the higher of the 2 scores. A part of hospitals’ Medicare payments is adjusted based on a total performance score that reflects3:

  • how well they perform compared to other hospitals, or
  • how much they improve their own performance compared to their performance during a prior baseline period

CMS bases hospital performance on an approved set of measures and dimensions grouped into specific quality domains.2 The applicable domains and their weighting changes for 2017 and 2018 and beyond are listed below:

Included in the Safety domain are the following conditions:

  • CAUTI | Catheter Associated Urinary Tract Infections
  • CLABSI | Central Line Associated Bloodstream Infections
  • CDI | Clostridium Difficile Infection
  • MRSA | Methicillin-Resistant Staphylococcus Aureus Bacteremia
  • SSI | Surgical Site Infections
    • Abdominal hysterectomy
    • Colon surgeries

What does it all mean? Let’s look at an average 300-bed Community Hospital with 48% of their patients being Medicare beneficiaries. If they have an inpatient Medicare revenue of $26,000,000 and received a $20,000 payment reduction for a condition/diagnosis, a maximum 2% penalty would be $400. That same reduction would be applied to EVERY inpatient Medicare claim submitted during the fiscal year and could result in a penalty of $520,000.

You might remember from our last blog that these measures are penalized in multiple programs—here, in VBP as well as the Hospital-Acquired Conditions (HAC) Reduction Program.

According to the World Health Organization (WHO), infections in healthcare settings are the most frequently occurring adverse event worldwide, leading to significant mortality and financial losses for healthcare systems.4

WHO reports that several factors can cause healthcare-associated infections (HAIs)4:

  • prolonged and inappropriate use of invasive devices and antibiotics
  • high-risk and sophisticated procedures.
  • immunosuppression and other severe underlying patient conditions
  • insufficient application of standard and isolation precautions

Join us for our next installment, “The Readmissions Reduction Program: How Are We Doing?”

Minimizing infection risk is an essential part of optimizing “The Triple Aim” of the Affordable Care Act. Eloquest Healthcare is committed to providing solutions that can help you reduce risk of conditions like a CAUTI, CLABSI, or SSI.

References:

  1.  Berwick, DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs 27, no.3(2008):759-769. Doi: 10.1377/hlthaff.27.3.759.
  2. Hospital Value-Based Purchasing. Department of Health and Human Services, Centers for Medicare & Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Published September 2016. Accessed January 16, 2017.
  3. Whitman E. Fewer Hospitals Earn Medicare Bonuses Under Value-Based Purchasing. Modern Healthcare. http://www.modernhealthcare.com/article/20161101/NEWS/161109986. Published November 1, 2016. Accessed January 16, 2017.
  4. Health care-associated infections Fact Sheet. World Health Organization. http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf. Accessed March 30, 2017.