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CMS Reveals Central Line Infection Rates, Finally

 |  By cclark@healthleadersmedia.com  
   February 09, 2012

For checklist guru Peter Pronovost, MD, this is a week to pop open that bottle of expensive champagne—if he does that sort of thing.

That's because for the first time, the Centers for Medicare & Medicaid Services has added to its Hospital Compare website the rates of central line-associated bloodstream infections, or CLABSIs, for specific hospital intensive care units, at least those collected to date. 

Next to getting hospitals to pay more attention to their central line processes, that's what Pronovost, a Johns Hopkins intensivist, and his collaborators have worked toward for the better part of the last decade.

The Centers for Disease Control and Prevention estimates these terrible, but preventable infections killed 10,000 of the 41,000 patients who acquired them while being cared for in U.S. intensive care units in 2009. Providing the additional care the infections required added $700 million to the healthcare bill.

The scores are posted in two ways on Hospital Compare. In the first, each hospital is listed as better, worse, or no different than the national average for the first quarter of 2011, with a link to a graph comparing the hospital's rate to the state rate.

In the second, hospitals are listed by Standardized Infection Ratio scores ranging from no infections, (0) to a high rate (4.57).  The SIR compares the number of CLABSIs to a national benchmark, adjusted for the type and size of the hospital or ICU, indicating whether it is worse, better than or at the national benchmark. A score of 1 means the hospital's CLABSI score was no different than hospitals of similar type and size.

Facilities are identified by provider number, and not by name. But provider numbers may be cross referenced with hospital names and SIR scores here



click to view table

Of the 3,378 hospitals with enough data to be eligible for a ranking, the highest SIR scores, indicating the highest rates of CLASBI,  were found here:

  • 4.57—Olympia Medical Center, Los Angeles, CA;
  • 3.60—River Region Health System, Vicksburg, MS;
  • 3.48—St. Petersburg General Hospital, St. Petersburg, FL;
  • 3.21Gaston Memorial Hospital, Gastonia, NC

Another 33 hospitals have rates above 2.

Perhaps because of dramatic implementation of Pronovost's checklist, these numbers are a dramatic reduction from two years ago when the CDC estimated 248,000 CLABSIs a year with between 31,000 to 60,000 deaths and a cost of $2.7 billion.

When I reached him at home earlier this week, Pronovost didn't hide his joy. By allowing the public to view the worst and best and everyone in between, hospitals would be all the more stimulated to improve, raising the bar even higher, he told me.

"We're delighted," he said.

"Other than media pressure (when a newspaper tackled CLABSI with a front page stories) there has been no other sanction. No regulatory role. No economic incentive to improve," Pronovost said. "It sure seemed like there needed to be something stronger that would say to a hospital, 'You know, you're a little above the average, or you're 10 times the national average. What are you going to do about it?' "

"CLABSI is one of the most accurately measured outcome indicators—a canary in the coal mine for quality—because we see that when hospitals focus their efforts, they can make dramatic reductions in these infections."

It is, he said, "a bellweather for where the country needs to go in paying for outcomes" instead of process measures.

Referring to a 750-hospital cooperative effort funded by the federal Agency for Healthcare Research and Quality, Pronovost talked about how hospitals proved that if they try, they can improve.

"Even in hospitals that were already hitting the benchmark, with rates of 1.1 or 1.5, many were able to cut them in half or more," Pronovost told me. "Now, whole states have CLABSI rates (averages) less than 1."

But even as some hospitals showed success, others appear stymied.

"We've also seen a number of hospitals that started out high, but didn't come down, and the public ought to be aware of that," Pronovost warned. "It simply says there's not enough leadership attention being paid to this."

With the exception of perhaps some burn units, which treat patients particularly vulnerable to infections, "we've seen rates come down in virtually every type of ICU.  So for the public to see hospitals with rates as high as 3 (and 4), that would really say that, well, it would raise a concern about the commitment to safety at that hospital."

About one third of hospitals have enough cases so far to justify a rate, but in late April, another three months of data will be posted, and in July, another three months until all hospitals have enough cases to compare.

For those hospitals that do have enough data, those with over 1.0 SIR are worse than national average, and some are much worse, including 37 with scores above 2.0.

The effort continues to reduce infection rates by 50% as soon as possible. It is funded with an $18 million contract from the federal Agency for Healthcare Research and Quality to the Health Research & Educational Trust, a non-profit research affiliate of the American Hospital Association.

Nancy Foster, the AHA's vice president for quality and safety and Pronovost say they're particularly pleased because of the type of data that is now posted.

Rather than using administrative discharge codes to tell whether a patient developed a central line infection, which are sorely inaccurate, CMS and CDC are using a much more specific clinical definition of CLABSI, as reported by each hospital, and collected by the National Healthcare Safety Network. The NHSN data, for example, includes central line patients who had a fever.

Using administrative data, which has been done in the past, "gets it right about one in four times," Pronovost says. "It's hard for me to think of any industry that would tolerate not being paid on a system that's wrong more than it's right."

Currently, hospitals providing this information are rewarded with a pay for reporting incentive of 2% of their Medicare reimbursement. Although about two dozen state health departments require hospital CLABSI reporting in their states, only a handful publish the data for public review.

Foster says that it's only a matter of time—perhaps just a year or two—that CLABSI, as well as catheter-associated urinary tract and surgical site infections will be not just reported to the CDC and CMS. Soon, hospitals with high rates will see their federal reimbursement checks reduced.

That's what's called for in Section 3008 of the Affordable Care Act, which imposes a 1% payment adjustment for hospitals with higher hospital-acquired infection rates for "discharges from an applicable hospital occurring during fiscal year 2015 or a subsequent fiscal year."

Foster says that most of the nation's hospitals are not waiting. "They're collecting this information themselves, getting their own data,—and knowing what is achievable, they can inform their own infection control processes."

So Pronovost, who 18 months ago called CLABSI prevention efforts like "the polio campaign for the 21st century, should go ahead and celebrate.  "This is a triumph for patients, a triumph for science, and hopefully a triumph for the U.S. healthcare system," he told me.

Download the Hospital Compare database.

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