CRBSIs: Reduce Infection Risks by Maintaining Integrity of Vascular Access Device Dressings

This is the first of a 3-part series focusing on catheter-related bloodstream infections (CRBSIs). As catheter use increases, bloodstream infections (BSIs) resulting from intravascular catheters have become a costly complication of health care.

To start, the terms CRBSI and central line–associated bloodstream infection (CLABSI) are often used interchangeably to describe intravascular device (IVD)–related bloodstream infections. However, there are differences. According to the Association for Professionals in Infection Control and Epidemiology (APIC)1:

  • CRBSI is a rigorous clinical definition, defined by precise laboratory findings that identify the central venous catheter (CVC) as the source of the BSI and that are used to determine diagnosis, treatment, and possibly epidemiology of BSI in patients with a CVC
  • CLABSI is a term used only for surveillance purposes to identify BSIs that occur in the population at risk (patients with central lines)

The costs of treating BSIs resulting from intravascular catheters range from $670 million to $2.68 billion annually in the US2, and up to $29,156 per incidence of a CLABSI.3 Unfortunately, CRBSIs are a common complication in patients admitted to the Intensive Care Unit. In fact, since 2008, hospitals are no longer reimbursed by the US Centers for Medicare and Medicaid Services for hospital-acquired infections (HAIs) like CRBSI.4 As a result, healthcare providers are under great pressure to decrease the rates of HAIs.

CRBSI Quality Improvement is a key objective for most practices and facilities. Because dressing disruption has been determined to be a major factor in the development of CRBSIs,5 the importance of ensuring the integrity of medical dressings and devices over extended periods of time cannot be overstated.

A large cohort of patients was studied in a randomized multicenter trial to determine the importance of dressing disruption on the risk for development of CRBSI.5 The results showed:

  • 67% (7,347 of 11,036) of the dressing changes were performed before the planned date due to soiling or undressing
  • When the final dressing was disrupted, the risk of catheter colonization or infection increased 12-fold

These results may have you questioning the durability of dressings. This was precisely what initiated another study, which evaluated the durability and associated costs of different CVC dressings.6

During the 12-month trial period, a total of 1229 CVC dressings were observed from 590 CVCs. The results demonstrated that few CVC dressing remained adherent for 7 days. While 1 dressing appeared to last longer than the others, it was still below the recommended standard and at increased cost. The study also considered the associated time and costs of the dressing changes.

While 1 dressing had a median duration of 68.5 [32-105] hours, the other 3 dressings compared at 43.5, 46.0 and 40.5 hours (P<0.001). There was no significant difference in the median dressing duration between the other 3 dressings (p=0.74).

The results of these studies demonstrate the need to ensure the integrity of vascular access device dressings between scheduled changes. It is clear this can’t be accomplished by a dressing alone. The superior adhesiveness of Mastisol® Liquid Adhesive has been clinically demonstrated. Using Mastisol®:

  • Reduces the likelihood of dressing disruption 7, 8
  • Minimizes the risk of infection by creating a lasting occlusive dressing barrier 9,10

For more information about Mastisol® Liquid Adhesive, please contact your sales consultant or Eloquest Healthcare®, Inc., call 1-877-433-7626 or visit www.eloquesthealthcare.com.

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 the risk of conditions like a CAUTI, CLABSI, or SSI.

Join us next time for the second of this 3-part series where we’ll explore the impact of CHG-compatible products on CRBSIs in our post entitled, “CHG Compatibility and CRBSI Reduction: Does it Matter?

References

  1. Accessed September 18, 2017.
  2. Shah H, Bosch W, Thompson KM, et al. Intravascular catheter-related bloodstream infection. Neurohospitalist. 2013;3(3):144-151.
  3. Scott RD II. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Centers for Disease Control and Prevention. March 2009. Available at: http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf.
  4. Stone PW. Changes in Medicare reimbursement for hospital-acquired conditions including infections. Am J Infect Control. 2009;37:17A-18A
  5. Timsit JF, Bouadma L, Ruckly S, et al. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med. 2012;40:1707-1714.
  6. Richardson A, Melling A, Straughan C, et al. Central venous catheter dressing durability: an evaluation. J Infect Prev. 2015;16(6):256–261.
  7. Pullen D. Quality Improvement Initiative to Improve Dressing Adherence Reveals Improved Dressing Adherence Observations on a Before-After Analysis. Presentation at AVA 2014 Annual Scientific Meeting, Washington DC, September 2014. Guide to the Elimination of Catheter-Related Bloodstream Infections. Association for Professionals in Infection Control and Epidemiology; Washington, DC: 2009. https://apic.org/.
  8. Niehaus S, McCord J. Improving Adhesion of Internal Jugular Dressings in the Intensive Care Unit. Presentation at Association for Vascular Access Annual Scientific Meeting in Orlando, FL, September 2016.
  9. Browne B, Moffo H. Quality Improvement Initiative Results in Fewer Dressing Disruptions and Improved Adherence to Best Practices. Presentation at Greater Cincinnati AACN Chapter, 28th Annual Trends in Critical Care Conference, Cincinnati, OH, April 2016.
  10. Boudreaux A. Ventriculostomy Dressing Process Improvement. Presentation at National Teaching Institute & Critical Care Exposition, Boston, MA, May 2013.

Procedure Kits: Where Common Sense Makes Financial Sense

PROCEDURES WHERE KITS HELP

  • Vascular Access Devices
    • PIV Starts
    • CVC Insertion
    • PICC Lines
  • Epidurals
  • Dressing Changes
  • Surgical Procedures

In our last blog, we reviewed how standardization of procedure kits can help your facility by increasing overall compliance to best practices. Yet another advantage of procedures kits is the financial benefit. A case in point is a study of phlebitis and infiltration rates within an institution following the conversion to a standard intravenous (IV) start kit, which showed dramatic effects by not only improving outcomes but decreasing costs as well.1

Nursing departments in this 700-bed facility tested a variety of IV starter kits and determined their best choice for the study. The kit they selected featured a window dressing, a prep of 2% chlorhexidine gluconate (CHG) with 70% isopropyl alcohol, catheter securement cushions, a tape strip, a 2″ x 2″ gauze pad, a latex-free tourniquet, and an extension set with needleless valve.

Hands-on training in the appropriate use of the kit was provided to hospital staff to achieve consistent usage. Outcomes were monitored by assessing phlebitis and infiltration rates at 6-month intervals on 250 patients per assessment.

The clinical results of implementing a standardized protocol/procedure kit not only met but exceeded the hospital staff’s objectives1:

  • Phlebitis rates were virtually eliminated
  • Infiltration rates were zero
  • Dwell times were extended from 72 hours to 96 hours

Beyond the beneficial clinical results were multiple cost avoidance advantages 1:

  • Annual real cost savings of 34% ($188,640)
  • Nursing time decreased from an average of 25 to 15 minutes per procedure
  • Reducing phlebitis rates resulted in lower expenditures and fewer unscheduled restarts
  • Extending catheter dwell time protocols saved nursing time and materials
  • Standardization reduced risk of costly infections
  • No need to hire additional nursing staff

Furthermore, the study resulted in some patient benefits as well 1:

  • Increased comfort (ie, fewer site complications, skin tears, unscheduled restarts)
  • Increased safety/lower risk of infection

This study demonstrated that standardization of procedure kits can not only help with overall compliance to best practices, but provide clinical and financial benefits as well. As you determine the appropriate components for your kits (eg, gowns, masks, caps, gloves, drapes, dressings, site prep solutions, etc.), consider the inclusion of Mastisol® Liquid Adhesive and Detachol® Adhesive Remover for any kit containing wound closure tapes or dressings:

  • Mastisol® Liquid Adhesive: Reduce the risk of infection by creating a lasting occlusive dressing barrier by incorporating Mastisol®
  • Detachol® Adhesive Remover: Miniminze risk of skin injury by implementing Detachol® for safe dressing removal

There are many manufacturers that specialize in providing and customizing kits for facility-specific needs. Mastisol® and Detachol® are available components for many kit manufacturers.

For more information about Mastisol® and Detachol®, please contact your sales consultant or Eloquest Healthcare®, Inc., call 1-877-433-7626 or visit www.eloquesthealthcare.com.

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.

Come back next time for the first of a 3-part series on catheter-related bloodstream infections (CRBSIs). You won’t want to miss it!

References

  1. Penny-Timmons E. Decreased costs/improved outcomes with standardized intravenous equipment. JAVA. 2005;10(1):20-23.

Procedure Kits Help Drive Compliance Best Practices

Most likely, your practice has standard operating procedures to ensure consistency and quality of care. In fact, an article in Modern Healthcare cited that 30% of inefficiencies in our healthcare system today are driven by a lack of standardization and a lack of care coordination.1

In the pursuit of creating “best practices” in your facility, one such area to consider is how procedure kits can help improve adherence. Two important advantages of doing so are:

  • Minimizing process variance so that all staff perform the procedure exactly the same way
  • Convenience of saving steps to locate and use materials independent of the procedure

PROCEDURES WHERE KITS HELP

  • Vascular Access Devices
  • PIV Starts
  • CVC Insertion
  • PICC Lines
  • Epidurals
  • Dressing Changes
  • Surgical Procedures

The Guidelines for the Prevention of Intravascular Catheter-Related Infections from the US Centers for Disease Control and Prevention (CDC) report that the risk for infection declines following standardization of aseptic care. Moreover, the insertion and maintenance of intravascular catheters by inexperienced staff potentially increased the risk for catheter colonization and catheter-related bloodstream infection (CRBSI).2

 

Standardized kits are also available for many surgical procedures and offer many of the same benefits of their vascular counterparts. Examples of these include incision and drainage (I&D) trays, arthroscopy kits, total knee replacement packs, and C-section setup packs. As the number of surgical procedures in the U.S. and the number of patients with increasingly complex comorbidities continues to rise, the stakes are becoming even higher.3

It is evident that standardization of procedure kits can help your practice or facility by having a positive effect on overall compliance to best practices. As you determine the appropriate components for your kits (eg, gowns, masks, caps, gloves, drapes, dressings, site prep solutionsetc), don’t forget to include Mastisol® Liquid Adhesive and Detachol® Adhesive Remover for any kit containing wound closure tapes or dressings:

  • Mastisol® Liquid Adhesive:  Reduce the risk of infection by creating a lasting occlusive dressing barrier by incorporating Mastisol®
  • Detachol® Adhesive Remover: Miniminze risk of skin injury by implementing Detachol® for safe dressing removal

There are many manufacturers that specialize in providing and customizing kits for facility-specific needs. Mastisol® and Detachol® are available components for many kit manufacturers.

For more information about Mastisol® and Detachol®, please contact your sales consultant or Eloquest Healthcare®, Inc., call 1-877-433-7626 or visit www.eloquesthealthcare.com.

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 the risk of conditions like a CAUTI, CLABSI, or SSI.

Join us next time to read our blog, “Procedure Kits: Where Common Sense Makes Financial Sense.”

References

  1. Standardizing care reduces costs, improves quality. Modern Healthcare. http://www.modernhealthcare.com/article/20150411/MAGAZINE/304119950. Published April 11, 2015. Accessed August 30, 2017.
  2. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis. 2011;52(9):e162-e193.
  3. 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.

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.