SSIs and Post-Op Dressings: What’s Missing?

You might remember from our previous blogs that certain measures, like surgical site infections (SSIs) are penalized in multiple programs of the Affordable Care Act—in the Value-Based Purchasing Program as well as the Hospital-Acquired Conditions Reduction Program. View Blog #2 and Blog #3 here.

SSIs are the most common and costly of all hospital-acquired infections in the US.1 Approximately 160,000-300,000 SSIs occur each year in the US and each SSI is associated with approximately 7–11 additional postoperative hospital-days per infection.2 SSIs are believed to total $3.5 billion to $10 billion annually in healthcare expenditures.2

Morbidity rates of SSIs are also concerning. Seventy-seven percent of deaths in patients with an SSI are directly attributable to the SSI.2 And did you know that patients with an SSI have a 2- to 11-times higher risk of death compared with operative patients without an SSI?2

Post-operative dressings have become a critical component of wound management and prevention of SSIs. A number of dressings are currently available that offer variable levels of desirable features:

Basic wound contact dressings3

  • Absorbent dressings: applied directly to the wound
  • Surgical absorbents: used as secondary absorbent layers in the management of heavily-exuding wound

Advanced dressings3

  • Vapor-permeable films: permeable to water vapor and oxygen, but not to water or micro-organisms; normally transparent
  • Hydrocolloid dressings: occlusive dressings composed of a hydrocolloid matrix attached to a base (possibly film or foam); fluid absorbed from the wound causes the hydrocolloid to liquify
  • Fibrous hydrocolloid dressings: composed of sodium carboxymethyl cellulose, which forms a gel when it comes into contact with fluid
  • Polyurethane matrix hydrocolloid dressings: consist of 2 layers—a polyurethane gel matrix and a waterproof polyurethane film designed to act as a bacterial barrier

Antimicrobial dressings3

  • Polyhexamethylene biguanide (PHMB) dressings: impregnated with the antimicrobial agent polyhexanide
  • Topical skin adhesives (glue-as-dressing): for closure of minor skin wounds and additional suture support; also used on an already closed wound as a dressing without an additional covering
  • Silver dressings4: release silver ions to bind to the DNA structures to affect cell function and respiration, effecting the cessation of bacterial replication
  • Chlorhexidine Gluconate (CHG) dressings: effective against a broad spectrum of gram-positive and gram-negative bacteria, yeasts, and some viruses; chlorhexidine is the active antimicrobial agent, and chlorhexidine gluconate is a commonly used form of chlorhexidine because it is colorless, odorless, and easily dissolves in water.5
  • Iodine dressings4: thought to disrupt microbial enzymes, proteins, and cell membranes through reacting with cell amino acids
  • Honey dressings4: used for centuries for its broad spectrum antimicrobial activity and ability to reduce the potential for wound infection and accelerate wound healing

Differentiations in dressings include varying degrees and combinations of transparency, absorbency, antimicrobial agent, adherence, conformability and water-resistance. What we have yet to see in a post-op dressing is one that integrates absorbency, transparency and antimicrobial. Perhaps soon?

Join us next time for our blog, “Antimicrobial Dressings: The Silver Mystique.”

References:

  • 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;224(1):59-74.
  • Anderson DJ, Podgorny K, Berrior-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35:605-27.
  • Dumville JC, Gray TA, Walter CJ, et al. Dressings for the prevention of surgical site infection (review). Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD003091. DOI: 10.1002/14651858.CD003091.pub4.
  • Hewish J. Understanding the role of antimicrobial dressings. Wounds Essentials 2012;1:84-90. http://www.wounds-uk.com/pdf/content_10457.pdf. Accessed February 13, 2017.
  • ChlorhexidineFacts.com website. http://www.chlorhexidinefacts.com/the-molecule.html. Accessed June 1, 2017.

CAUTI Prevention: A Nurse-Driven Quality Improvement Study

As posted previously, the Affordable Care Act (ACA) established penalty measures for the performance of acute care hospitals. In fact, some measures are penalized in multiple programs1,2:

  • VALUE-BASED PURCHASING PROGRAM (VBP) – For more information about the VBP Program, see our previous blog
  • HOSPITAL-ACQUIRED CONDITIONS (HAC) REDUCTION PROGRAM – For more information about the HAC Reduction Program, see our previous blog.

According to the Centers for Disease Control and Prevention (CDC), urinary tract infections (UTIs) are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network.3

Among UTIs acquired in the hospital, approximately 75% are associated with
 a urinary catheter3

What can be done?
A poster, Taking the Next Steps for Patient Safety and Excellence in CAUTI Prevention, was recently presented at the 44th Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC).The poster described a nurse-driven quality improvement initiative designed to:

  • reduce urinary device days
  • decrease the Foley Utilization Rate (FUR), which is calculated by dividing the number of Foley catheter days by the number of patient days5
  • lower the CAUTI rate

The initiative sought to determine if switching from an indwelling (Foley) catheter to a different male external continence device (ECD) could reduce the negative outcomes associated with the Foley catheters.

The results of switching to an ECD resulted in:

  • a 46% decrease in total urinary device days
  • decreased the FUR from a high of 0.41 in to a low of 0.19 (with a 0.25 average)
  • lowered the CAUTI rate to 0 (See Figure 1 below.)

Figure 1. CAUTI Rate

The poster’s author noted some important clinical implications:

  1. Adherence to appropriateness criteria for indwelling catheter placement can help prevent unnecessary risk for CAUTIs.
  2. Use of an ECD as an alternative to indwelling Foley catheters may reduce the CAUTI incidence rate.
  3. The intervention resulted in an overall decrease in total urinary device days and Foley catheter days.

The ECD used and represented by an image on the poster was the ReliaFit® Male Urinary Device marketed by Eloquest Healthcare®:

The results clearly support the poster’s title and provide impressive rationale for taking proactive steps for preventing CAUTIs in the acute care hospital setting.  Download the poster here.

Come back to read our next blog, “SSIs and Post-op dressings: What’s missing?”

References:

  1. 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 2015. Accessed June 1, 2017.
  2. 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 June 1, 2017.
  3. Healthcare-associated Infections: Catheter-associated Urinary Tract Infections (CAUTI). CDC website. https://www.cdc.gov/hai/ca_uti/uti.html. Accessed June 1, 2017.
  4. Quayle BL. Taking the next steps for patient safety and excellence in CAUTI prevention. Poster presented at: APIC 44th Annual Conference. June 14, 2017; Portland, Oregon.
  5. Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events. CDC website. https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf. Published January 2017. Accessed June 1, 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.

A Breakdown of the ACA and What it Means to Your Hospital

The Affordable Care Act (ACA) created a national quality strategy for the triple aim of better care, healthy people and communities, and affordable care.1 It also initiated a significant transition from fee-for-service to value-based care.

Continue reading