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Update on hospital acquired conditions and “Never” events per CMS (things Medicare won’t pay for) (MC)

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Note from Mary:

Here is an update on CMS (Medicare’s) non payment for medical errors project. There are two types of scenarios, and they are treated somewhat differently: 1) Hospital-Acquired Conditions (HAIs); and 2) “Never” events (examples of never events are: Surgery on a wrong body part; Surgery on a wrong patient; and Wrong surgery on a patient)

This is just for reference or your bedtime reading! You will not be tested.

There are now 10 HAI conditions (sometimes you see 11, when the conditions are itemized differently). These are the conditions for which, if acquired IN a hospital after admission, hospitals won’t be reimbursed by Medicare. Nurses are going to be feeling particular pressure to make sure that these events do not occur. I added the diabetes-related definitions in red below. There is also an article specifically on managing glucose control at the bottom—that is one of the newer conditions that CMS has added

Hospital-Acquired Conditions

Section 5001(c) of Deficit Reduction Act of 2005 requires the Secretary to identify conditions that are: (a) high cost or high volume or both, (b)result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence‑based guidelines.
On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, CMS included 10 categories of conditions that were selected for the HAC payment provision. The IPPS FY 2009 Final Rule is available in the Statute/Regulations/Program Instructions section, accessible through the navigation menu at left.
The 10 categories of HACs include:

  1. Foreign Object Retained After Surgery
  2. Air Embolism
  3. Blood Incompatibility
  4. Stage III and IV Pressure Ulcers
  5. Falls and Trauma
    • Fractures
    • Dislocations
    • Intracranial Injuries
    • Crushing Injuries
    • Burns
    • Electric Shock
  6. Manifestations of Poor Glycemic Control
    • Diabetic Ketoacidosis (A life threatening condition, most common with Type I diabetes in which the patient doesn’t have enough insulin to process blood sugar. The body then begins to break down fat for energy, which produces toxic acids called ketones)
    • Nonketotic Hyperosmolar Coma (A serious complication that occurs with Type 2 diabetes when blood sugar gets too high and the body becomes severely dehydrated)
    • Hypoglycemic Coma (A coma caused by extremely low blood sugar)
    • Secondary Diabetes with Ketoacidosis (Diabetes caused by another disease or a drug with the complication of ketoacidosis)
    • Secondary Diabetes with Hyperosmolarity (Diabetes caused by another disease or drug with the complication of hyperosmolarity)
  7. Catheter-Associated Urinary Tract Infection (UTI)
  8. Vascular Catheter-Associated Infection
  9. Surgical Site Infection Following:
    • Coronary Artery Bypass Graft (CABG) – Mediastinitis
    • Bariatric Surgery
      • Laparoscopic Gastric Bypass
      • Gastroenterostomy
      • Laparoscopic Gastric Restrictive Surgery
    • Orthopedic Procedures
      • Spine
      • Neck
      • Shoulder
      • Elbow
  10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
  • Total Knee Replacement
  • Hip Replacement

Payment implications will begin October 1, 2008, for these 10 categories of HACs.

What Medicare is doing: Since October 1, 2007, hospitals have been required to report on their Medicare claims if any of the first eight selected conditions were present at the time the patient was admitted to the hospital, and beginning October 1, 2008, will have to report on the remaining conditions as well. If at discharge, there is a selected condition that was either not identified by the hospital as present on admission, or could not be identified based on data and clinical judgment at admission, it is considered hospital-acquired. To encourage hospitals to avoid hospital-acquired conditions, beginning October 1, 2008, Medicare will no longer pay hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of the listed conditions if it was hospital-acquired. Medicare prohibits the hospital from billing the beneficiary for the difference between the lower and higher payment rates.
Medicare will pay for physician and other covered items or services that are needed to treat the hospital-acquired condition, including the costs of post-acute care that would not have been needed for the patient’s initial medical problem, but are needed because of the hospital-acquired condition.

Medical Errors That Should Never Happen (“Never Events”)
What they are: There are some events that should never happen in a hospital. When they do occur, they can cause serious injury or death to the patient. The National Quality Forum (NQF) has defined these as Serious Reportable Adverse Events, commonly referred to as “never events.” These events are also likely to be very costly both for the beneficiary and the Medicare program. Some examples of “never events” include:

  • Surgery on a wrong body part
  • Surgery on a wrong patient
  • Wrong surgery on a patient

What Medicare is doing: In most cases, Medicare pays only for items or services that are reasonable and necessary for the treatment of the patient’s condition, or certain preventive services required by the Medicare law. For the three wrong surgeries listed as examples above, Medicare is opening a National Coverage Decision process to look at how to ensure that patients get necessary care, but that the Medicare program would not pay the doctor and the hospital for an erroneous surgery.

Hospitals Are Working To Control Undiagnosed Diabetes
By Geri Aston
Patients with high blood sugar levels are at risk for a wide range of conditions. Early testing and new treatments help keep them out of danger.

Clinical Management Series
Clinical Management is a bimonthly series that examines specific disease or treatment areas. Clinical Management aims to uncover trends in technology, staffing, financing and other issues of concern to senior hospital executives Our April installment will look at cardiology services.

In 1997 when Integris Baptist Medical Center in Oklahoma City began its effort to improve the quality of care for inpatients with high blood sugar, it was way ahead of the curve. “No one was talking about blood sugar then,” says Stanley F. Hupfeld, president and CEO of Integris Health, the medical center’s parent.

A year earlier Baptist had begun a collaboration with the Ediba Diabetes Center of Excellence, also located in Oklahoma City. Officials there recognized that the hospital needed to improve treatment of patients who came in because of a serious illness but who also had diabetes or unrelated high blood sugar, says Charles A. Bryant, M.D., who at the time was Integris vice president of clinical integration. A top Baptist endocrinologist embraced the message and quickly convinced hospital leadership that change was necessary.

“The thing that impressed me the most was when the endocrinologists said there is a significantly high percentage of patients who had undiagnosed diabetes, and these patients were having procedures,” Hupfeld says. Patients with untreated hyperglycemia have a higher risk of infection, return to surgery and other serious complications, he notes.

So the hospital developed a program of early identification and management of patients with blood sugar problems. It started with educating all staff who handled these cases—doctors and nurses, respiratory therapists, pharmacists, even unit clerks and coders, Bryant says.

The program, which has evolved over time, includes standardized, evidence-based treatment protocols for handling incidences of high and low blood sugar; a team of two clinical nurse specialists and an endocrinologist who deal with particularly tough cases; and an electronic information system that fires alerts to the team when a patient has blood sugar that is too high—hyperglycemia—or too low—hypoglycemia.

When Baptist’s initiative began in 1997, about 9.4 million Americans had diagnosed diabetes. By 2007, that figure had jumped to 17.9 million, and an estimated 5.7 million had the disease but were undiagnosed, according to the Centers for Disease Control and Prevention. The American Diabetes Association estimates that another 57 million people have pre-diabetes, blood sugar levels that are higher than normal but not yet in the diabetes range.

Diabetics are at higher risk for a variety of conditions that could land them in the hospital, including heart and kidney disease; limb ulcers, infections and amputation; and eye disorders. Their diabetes also makes them higher-acuity patients when they arrive at the hospital, notes Bryant, who is now president of Evident Health Services, an Oklahoma City diabetes management service and clinic.

The enormity of the epidemic has sparked a growing recognition in the hospital community that something needs to be done, he says.
Indeed, more hospitals are following Baptist’s lead and instituting programs to better manage hyperglycemic patients. “Over the past five years or so, there has been increased awareness in this regard, and many hospitals are trying to do better,” says Etie Moghissi, M.D., secretary of the American Association of Clinical Endocrinologists and clinical associate professor of medicine at the University of California, Los Angeles.

Hospitals span the continuum, she says, with some doing quite well managing inpatients’ sugar levels and some just starting to think about the issue. “There is no hospital that is at 100 percent of what they need to do, because it is something that is complicated,” says Moghissi, who co-chaired an American College of Endocrinology and American Diabetes Association task force ( that issued a consensus statement and recommendations on inpatient diabetes and glycemic control in 2006. “These patients have multiple medical problems.”
Moghissi and others stress that the focus now is not just on diabetic patients, but any patient with hyperglycemia. “It really doesn’t matter the cause of the high blood sugar. It’s the high blood sugar we worry about,” she says.

Making the Case
Developments in the last decade not only provide strong rationale for hospitals to establish glycemic control programs, but also make it easier for them to do so.

These include myriad studies showing that tight control of blood sugar levels improves patient outcomes and that glycemic management can save hospitals money, the introduction of better insulin products, and the roadmap for action presented by the 2006 ACE/ADA recommendations.
Intensive care units were on the front end of the research and protocol development trend, encouraged by a 2001 Belgian study that showed tight glycemic control in a surgical ICU significantly reduced mortality, bloodstream infections, acute renal failure and red blood cell transfusions.

One of the first U.S. facilities to take action was Stamford (Conn.) Hospital. The medical-surgical ICU in February 2003 instituted a protocol, developed by a multidisciplinary team, calling for strict blood sugar control.

he program, which has been tweaked over time, was a major shift in practice, says James S. Krinsley, M.D., Stamford’s director of critical care and the driving force behind the initiative. The blood sugar of all ICU patients is monitored, typically with a bedside finger-stick test, either hourly if they’re on IV insulin or every three hours if they’re getting subcutaneous insulin injections to make sure they’re within the targeted range.

Using standardized care models is the key to success, Krinsley notes. “You can’t do a glycemic program if you have six different protocols in place in the same ICU,” he says.

Many more hospitals are now talking about glycemic control in the ICU, Krinsley says. However, widespread adoption is hindered by physicians’ and nurses’ fear of hypoglycemia as an unintended consequence of treating hyperglycemia, their uncertainty about the new protocols’ health benefits, and concerns that frequent patient monitoring increases workload.
At Stamford, staff education and feedback showing positive results, including reduced patient mortality, quickly turned physicians’ and nurses’ attitudes around. The hospital won a Joint Commission Codman Award in 2004 for its protocol, which has been carried out without increasing the number of nurses.

Krinsley created and operates an electronic database that now has 10,000 patients in it. “I’m continually pumping out information about what’s going on in the ICU and putting it in front of the nurses. That’s what really got them hooked into this project,” he says. The database allows the staff to track and investigate cases of hyper- and hypoglycemia and change the protocol if necessary.

The ability to electronically “track and trend” blood sugar levels is necessary for quality improvement, Moghissi says. Although many hospitals lack integrated information systems with these capabilities, most could create them in-house, she adds.

The success of ICU glycemic control efforts and studies showing patient benefits outside of critical care have spurred some hospitals to expand their programs beyond intensive care units. Proponents emphasize the importance of screening all patients for hyperglycemia to catch those who have undiagnosed diabetes and those who have unrelated hyperglycemia.

Better Protocols
The strain of hospitalization and serious illness, as well as some medications, can aggravate patients’ diabetes. The same factors can cause a problem unrelated to diabetes known as stress hyperglycemia in patients with no history of the disease. As a result, many seriously ill patients with hyperglycemia who are not in the ICU must be treated with subcutaneous insulin injections.

Over the past few years, hospitals have begun to develop new protocols for these patients that are better than the commonly used sliding scale method of insulin replacement, Moghissi says. With the sliding scale, clinicians wait until a patient’s glucose level has spiked too high and then administer insulin. The technique in recent years has been proven ineffective and sometimes dangerous because patients often swing from blood sugar highs to lows, she explains.

The new protocols take a different approach. They involve administering long-acting basal insulin, which serves as background insulin to steady the patient’s blood sugar throughout the day, and quick-acting prandial insulin administered at meal times to prevent spikes in reaction to food. Correctional doses are given if a patient’s glucose level rises too high at any point. This system prevents the blood sugar swings that sliding scale insulin can produce.

A standardized insulin regimen decreases the chance of mistakes. “Learning one protocol well versus trying to do 15 different sliding scales for 15 different physicians—a logical perspective would say you’re going to reduce a lot of errors by doing that,” Bryant says.

The new treatments were advanced in 2001 by the introduction of genetically modified insulin, called insulin analogs. These products allow patients to get insulin in a way that more closely mimics the body’s normal functioning.

Many physicians say insulin analogs are safer for patients. Prandial insulin analogs are an improvement over regular insulin because they act so quickly, says Kathie L. Hermayer, M.D., medical director for diabetes services and director of the Diabetes Management Service at the Medical University of South Carolina. Patients can be given a prandial insulin analog when their meal arrives, which prevents dangerous lows that can occur if regular insulin is administered but then the meal cart arrives late. MUSC has almost completely switched to insulin analogs for subcutaneous use, she says.

But some clinicians are reluctant to abandon the old way of doing things. At MUSC, the shift to basal, prandial and correctional insulin required a shift in mind-set, Hermayer notes, “because the way physicians and nurses have been raised, and probably pharmacists and dieticians, is in this culture of the sliding scale.”
Stamford Hospital initiated an insulin analog protocol in 2007 as a quality improvement program but makes it voluntary for doctors. “We don’t want to make any physicians in the community feel that we are forcing them to change the standard,” says Richard M. Weinberg, M.D., chief quality officer. The hospital has seen a gradual increase in analog adoption and a reduction in sliding scale insulin use. He estimates that 60 percent to 80 percent of hyperglycemic patients are being treated under the new regimen. The hospital plans to study the outcomes of protocol and nonprotocol patients this year.

As in the ICU, clinicians in medical-surgical areas worry the new regimens will cause hypoglycemia. “But if you have systems in place so you provide insulin properly and the patients are monitored, you can actually decrease hypoglycemia,” Moghissi says.

Financial Considerations
There is growing evidence that glycemic control not only improves quality but also saves hospitals money in the long run.

For example, Integris spent about $3 million on its program from inception in 1997 to 2005. Most of the money was spent at the front end. The return was about $12 million over the same period. “That focus on getting the program going and having the ability to sustain it until you see the returns is one of the key challenges,” Bryant says. “For a four-to-one return on your investment, it’s worth sticking with it.”

At Stamford, Krinsley ran a study of the first 800 patients who were seen under the ICU glycemic control protocol compared with the last 800 non-protocol patients. He calculated the protocol’s annualized cost savings at $1.3 million. The savings come from reductions in length of stay, ventilator days and resource utilization. “It’s not like you’re paying for the quality—the quality pays for itself many times over.”

The Centers for Medicare & Medicaid Services in October 2008 gave hospitals even more of a financial incentive to improve care for patients with blood sugar issues. It added several problems associated with poor glucose control to the list of health care-acquired conditions for which Medicare will not pay. The list also includes several conditions in which diabetes can play a major role, such as pressure ulcers, injuries from falls and several types of infection.

“This is an opportunity for hospitals to proactively try to minimize these events, which are very costly because they are not going to get paid for them,” Moghissi says. “Instead of waiting a year from now and saying, gosh, let’s see how many denials we had because of these events, the smart ones can put systems in place to address these issues and try to minimize them.”

Still, many hospitals worry about the cost of instituting glycemic control programs. “Implementing it is laborious and requires capital and time, so in tough times these are the kind of things that get pushed to the back burner,” Bryant says.

The 2006 ACE/ADA consensus statement addresses cost and other barriers to hospital adoption of glycemic control programs. It also highlights strategies that have proven effective in improving management of diabetic inpatients.

The first recommendation is that glucose control for inpatients with diabetes or hyperglycemia must become an institutional priority. “It needs to be recognized that this is important and resources put in place to deal with it,” Moghissi says. “So administration support is very, very essential.”—Geri Aston is a freelance writer in Chicago.

This article 1st appeared in the February 2009 issue of HHN Magazine.