More than 350 hospitals in 22 states in a national pilot project to tackle central line-associated bloodstream infections in their adult intensive care units are reporting CLABSI reductions of 35%, according to the Agency for Healthcare Research and Quality.
An interim report issued Tuesday by AHRQ, On the CUSP: Stop BSI, found that CLABSI rates dropped from an average of 1.8 infections per 1,000 central line days to an average of 1.17 infections per 1,000 central line days in ICUs that participated in the project.
The project is led by the Health Research & Educational Trust, an affiliate of the American Hospital Association. "AHRQ's vision of spreading a proven method of reducing these infections to all states has demonstrated its innovative leadership in patient safety, and HRET is proud to be part of this groundbreaking work along with Johns Hopkins and the MHA Keystone Center," said John R. Combes, MD, AHA senior vice-president and senior fellow at HRET, in a statement.
About 1,100 hospitals in 45 states, the District of Columbia, and Puerto Rico have enrolled in the national effort, which is based on a Michigan Health & Hospital Association Keystone Center project that dramatically reduced CLABSI rates in Michigan hospitals.
The On the CUSP: Stop BSI initiative, is scheduled to continue through 2012. Participating hospitals are given training developed by Peter Pronovost, MD, at Johns Hopkins University Quality and Safety Research Group. Participating hospitals also receive data reports and implementation guidance from the MHA Keystone Center and collaborate with other participating hospitals in their state.
HealthSouth Corp. said it has received permission from the state of Florida to build a $21 million, 40-bed hospital in Ocala that will specialize in physical rehabilitation for patients with trauma, brain and orthopedic injuries, strokes, and other major illness or injuries.
"This state-of-the-art hospital will provide a new and different type of service which will further augment the already strong continuum of healthcare services provided in Ocala/Marion County," Linda Wilder, president of HealthSouth's Southeast region, said in a media release. "We look forward to working with other providers in the community to integrate this new service in Marion County."
Construction on the 49,000-square foot Ocala Rehabilitation Hospital of Marion County, LLC is expected to begin by the end of 2011. Once it is operational, the hospital will create around 112 new, full-time jobs.
With 81,000 residents over the age of 65, Marion County is the largest county in Florida that doesn't have access to inpatient rehabilitation—a number that is expected to grow at a rate of 18%, faster than any other county in Florida, Wilder said.
"Currently, Marion County residents have very limited access to an inpatient rehabilitation hospital requiring patients and their families to travel to Gainesville or Spring Hill. This new hospital will ensure that residents have appropriate and reasonable access to the latest rehabilitative treatment and technology in a hospital setting," Wilder said.
Birmingham, AL-based HealthSouth is the nation's largest provider of inpatient rehabilitative healthcare services, with operations in 26 states, including nine inpatient rehabilitation hospitals and one long-term acute care hospital in Florida.
Rex Healthcare in Raleigh, NC has been ordered to pay the federal government $1.9 million, plus interest, to settle whistleblower allegations that its flagship hospital submitted false claims to Medicare to get pricier inpatient reimbursements for kyphoplasties and other minimally invasive procedures, the Justice Department announced this week.
The allegations arose from a whistleblower lawsuit filed in 2008 in federal court in Buffalo, NY, by Craig Patrick and Charles Bates, former employees of the medical device company Kyphon. The two men will receive a total of $80,000 of the settlement proceeds for kyphoplasty-related claims, DOJ said.
"We pursue cases like this because when hospitals submit false claims in order to increase their Medicare reimbursement, as we allege here, it artificially drives up the cost of healthcare, leaving taxpayers to foot the inflated bill," Tony West, Assistant Attorney General for the Justice Department's Civil Division, said in a media release announcing the settlement.
Rex Hospital is the second North Carolina hospital to settle Medicare fraud charges involving kyphoplasties. Presbyterian Orthopaedic Hospital in Charlotte paid the federal government more than $637,000 in December to settle fraud charges.
In May, 2008, Medtronic Spine LLC, the corporate successor to Kyphon Inc., agreed to pay the federal government $75 million to settle Medicare settle false claims allegations that it advised hospitals on how to improperly bill for the procedures. Since then, 26 hospitals have negotiated kyphoplasty settlements with DOJ.
The alleged improper billing at Rex Hospital took place from 2004 through 2007, DOJ said.
Federal prosecutors have used the False Claims Act to recover $5.3 billion since January 2009 in cases involving fraud against federal healthcare programs. DOJ's total recoveries in False Claims Act cases since January 2009 have topped $6.8 billion.
Linda Butler, MD, CMO of Rex Healthcare said in a phone interview with HealthLeaders Media:
"We don't feel like we did anything wrong. We were following rules at the time but it was probably easier and cheaper to settle than to fight the government on this. We were performing this procedure on elderly frail patients in their 70s and 80s who were in excruciating back pain and they had a lot of problems like cancer and cardiac issues. Some even spent the night in the ICU due to their frail state. During that time we were following the InterQual third-party billing recommendations to bill this as an inpatient procedure. In 2007 when it was deemed to be an outpatient procedure we began billing it as outpatient. When the government decided to retroactively penalize people who had billed it as inpatient before 2007 we were caught with that. We didn't think we did anything wrong. We think it is unfair, but it was probably better to settle."
Educating and training healthcare personnel and maintaining safety protocols are the key areas of emphasis in updated federal guidelines designed to prevent catheter-related bloodstream infections.
"Catheter-related bloodstream infections—like many infections in healthcare—are now seen as largely preventable," said Naomi O'Grady, MD, medical director of procedures, vascular access, and conscious sedation services at the National Institutes of Health Clinical Center Critical Care Medicine Department, and lead author of the study: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.
"Implementation of these critical infection control guidelines is an important benchmark of healthcare quality and patient safety," O'Grady said in a media release.
The guidelines were created by NIH, the Centers for Disease Control and Prevention, and the Healthcare Infection Control Practices Advisory Committee, in consultation with 14 other healthcare professional organizations.
In addition to training for healthcare personnel and fortifying sterile barriers during catheter insertion, the guidelines also call for: using 'maximal sterile barrier precautions' during central venous catheter insertion; cleaning skin with the antibacterial scrub chlorhexidine: using a > 0.5% chlorhexidine skin preparation with alcohol for antisepsis; avoiding routine replacement of central venous catheters as a strategy to prevent infection; and using antiseptic/antibiotic impregnated short-term central venous catheters and chlorhexidine impregnated sponge dressings if the rate of infection is not decreasing using the first four strategies fail, the guidelines said.
The guidelines, which replace the 2002 edition, also recommend using "bundled strategies" and documenting and reporting rates of compliance with all components of the bundle as benchmarks for quality assurance and performance improvement. The report was published Friday in Clinical Infectious Diseases, and is available on CDC's HICPAC website. The guidelines will also be included in a special supplement to the American Journal of Infection Control.
The Department of Health and Human Services has prioritized tracking, reporting, and preventing costly and dangerous bloodstream infections, with a national goal of reducing central line-associated bloodstream infections by 50% by 2013.
Starting this year, hospitals must track and report CLABSIs in ICUs to qualify for an annual 2% Medicare payment increase. Hospitals will report their infection rates to CDC's National Healthcare Safety Network, and the data will be shared with the Centers for Medicare & Medicaid Services, and made public later this year on CMS' Hospital Compare Web site. CDC and the Agency for Healthcare Research and Quality are also providing state health departments with funding to better track and prevent HAI's at the state level, CDC said.
A recent CDC report showed a 58% decrease in CLABSIs among hospital ICU patients in 2009, compared to 2001. In 2009 alone, reducing these infections saved about 3,000 to 6,000 lives and about $414 million in extra medical costs, compared with 2001.
"Education and reinforcement of care and maintenance protocols among staff is key. We all have a role to play in protecting patients from these infections," O'Grady said.
For at least one analyst, there are plenty of details but not too many surprises in the sweeping 429- page proposed guidelines the Centers for Medicare & Medicaid Services issued last week on accountable care organizations.
"The deliberate process they took to issue this two months after we expected it shows they were being very cautious," said Paul Keckley, executive director of the Deloitte Center for Health Solutions, in an interview with HealthLeaders Media.
"They were very deliberate in the language. I've read it twice. The amount of effort they built into calibrating the quality metrics, the indices of the five domains, the waivers, the safety zones, the antitrust issues. They were pretty thoughtful about balancing all of those moving parts of what is a pretty complicated concept," he says.
Keckley said that anyone who's been following the ACO movement wouldn't be surprised to note that the overarching concern in the guidelines is physician-hospital alignment.
"You have value-based purchasing, and episode-based payments and avoidable readmissions, and the medical home, the ACO, physician quality reporting initiative and the physician self-referral language and you step back and see they are compelled by the vision of integrated systems," he says. "That to me is the big cake here."
Healthcare industry groups have offered guarded support for ACOs, but are still sifting through the details. America's Health Insurance Plans, for example, has raised concerns that hospitals and ACO collaborations could forge monopolies for their service areas and dictate higher prices.
Keckley says the proposed guidelines attempt to deal with the "unforeseen."
"I read carefully the discussion of antitrust safety zones, how primary service areas are defined, the 30% threshold," he says. "The language in the guidance suggests that they have been very thoughtful about waivers and antitrust. And, they have maybe been cautious thinking about what will happen if commercial health plans piggyback the ACOs and use them as their contracting organizations. Does that consolidate power? Does it create cartels? I was impressed by the granularity of the language in that section."
The American Hospital Association has raised concerns that the guidelines might not adequately address clinical barriers among caregivers. Keckley says that by identifying the 65 measures in five quality areas – including patient safety, patient experience, care coordination, preventive care, and at-risk populations – the feds "are going as about as far as they can."
"Clinical integration is really a loaded term because it means the doctors and hospitals have to work together and that is not easy," he says. "So, it's one thing to get the evidence and build the evidence-based guideline algorithms. It's another thing to get everybody in one room and say 'we all agree.' I don't think that is a shortcoming of the guidance as much as it is the history of our industry. It's tough for organizations to work together."
The American Medical Association raised concerns that the capital requirements for ACOs might be too highfor many physicians. "It's a fair concern anytime you inject a change into the system as to the cost of implementing something new and where is that cost borne," Keckley said. "I read explicitly that CMS is asking for guidance around several areas. This is one of four identified as an area looking for input."
Keckley says he expects CMS will tinker with the guidelines, but he's not sure what sorts of changes might occur before the Jan. 1, 2012 implement date. "I can't imagine they will alter quality reporting. In year one its pay for reporting, not pay for performance per se. The model for the shared savings and risk, that threshold in the one-sided model that seems to be a range, they will have to be a little more explicit there," he said. "But this is A not much of a surprise to most of the folks who've been watching, so I don't think the January 1 deadlines impose major constraints unless you've convinced yourself we aren't going down the ACO path."
It's important to remember, Keckley points out, that the program is voluntary.
"I don't think that means you're not going down the physician-hospital integration path. It means you may not apply to be an ACO," he says. "If you chose that route, no harm no foul. Folks will chose other routes to physician-hospital alignment. And if you're choosing to go the ACO route this answered a lot of questions."
There are two kinds of surveys: Those that surprise you and tell you what you didn't know, and those that reaffirm what you already knew. Both have their value.
A survey of healthcare workers by Chicago-based recruiters CareerBuilder definitely falls into the second category and confirms what we already know. Namely, that healthcare workers –- like everyone else –- expect to earn a decent living for their labor. Salary and benefits are not, however, what attracted them to healthcare as a career choice, and they're not what make them happy. Remember that in this era of chronic staff shortages and turnover, and aggressive organized labor campaigns.
"Although salary and benefits are important, lower-cost factors, such as mentoring, career-path planning, training and support also greatly influence healthcare employees to apply to and stay at a job," Sanja Licina, senior director of Talent Intelligence at CareerBuilder, said in media release announcing the survey. "With healthcare organizations battling for top talent and facing high demand for positions, it's important for employers to take the temperature of their staff to best meet their needs, as well as keep a finger on the pulse of job seekers."
The survey -- Health Care Workers Reveal Workplace Challenges and Factors That Influence Turnover –- of 1,104 healthcare workers and 310 healthcare employers involved in hiring decisions was compiled between May 1 and June 30, 2010.
Here are some of its key findings:
Of healthcare workers who responded 51% said that a lack of advancement opportunities was the top challenge they faced, and 40% cited work overload as their biggest challenge.
Nurses are more concerned with a good environment than with the amount of money they make. Nurses, the hardest providers to recruit and retain, ranked salary fifth (35%) on their list of biggest workplace challenges. Topping their list was insufficient staff (49%) and a lack of advancement opportunities (49%).
Tenure rates for nurses are low across different healthcare organizations. Analysis of CareerBuilder databases revealed that registered nurses have a median tenure of 1.4 years. Physicians' offices see the lowest nurse turnover, with median job tenure of 1.57 years, while nursing care facilities have the highest at .97 years. Falling in the middle were kidney dialysis centers (1.23) and home healthcare services (1.17).
A wide disconnect exists between benefits offered by employers and what employees say their organizations provide. Fifty-seven percent of respondents said that in-house skills trainings were offered by their employer, however, 68% of healthcare employers said they provided the perk. Licina said this disconnect shows that while healthcare organizations may be offering valuable perks, they are not communicated effectively to employees.
Patient-to-staff ratios are strained, leaving workers spread thin with little time for career development. Fifty-seven percent of healthcare workers said that patient-to-staff ratio is worsening, allowing less time for professional development and career advancement and requiring more time on day-to-day duties.
Outside of a few specifics, such as the alarmingly short length of nurse tenure, there is nothing in the survey that leaps out as a surprise. Spend a few minutes talking to nurses and they'll say as much.
Still, it's troubling to see that even as healthcare workers offer specific, actionable workplace grievances, management either isn't acting on the complaints, or isn't communicating how it is addressing the complaints.
In some ways, these survey results are good news for cash-strapped hospitals. Healthcare workers say quite clearly that it isn't just about money. That's believable. They put patient care and workplace conditions and professional development above compensation. There aren't too many industries that can make that boast about their workforce.
What the survey is really saying is that healthcare workers are not apathetic. They want to do a good job, and they're probably willing to buy into your mission, if you pay attention to their fairly reasonable concerns.
Job growth in the healthcare sector is on an uptick, Bureau of Labor Statistics data and preliminary data show.
Hospitals created 10,200 new jobs in March and 19,600 new jobs in the first quarter of 2011, easily outstripping the 3,700 hospital jobs created in the first quarter of 2010, according to the BLS.
The healthcare sector – everything from hospitals to podiatrists' offices to kidney dialysis centers – created 36,600 new jobs in March, and 82,600 new jobs in the first quarter, and now employs slightly more than 14 million people. Healthcare created 63,200 new jobs in the first quarter of 2010, BLS preliminary data show.
Healthcare sector employment nudged over the 14 million jobs threshold in March for the first time, with 4.7 million jobs at hospitals, nearly 6.1 million jobs in ambulatory services, more than 2.3 million in physicians' offices, and nearly 3.2 million jobs at nursing homes and residential care facilities, BLS preliminary data show.
Ambulatory services accounted for half of the new jobs created in the healthcare sector, with 17,500 new jobs in March, and 45,600 new jobs for the quarter. Ambulatory services created 50,000 new jobs in the first quarter of 2010, BLS preliminary data show.
Physicians' offices reported 7,600 new jobs in March, and 16,500 new jobs in the first quarter, compared with 4,900 jobs in the first quarter of 2010. Nursing and residential care facilities also showed strong job growth in March, creating 8,800 payroll additions for the month, and 17,400 payroll additions in the first quarter, BLS preliminary data show.
BLS data from February and March is preliminary and may be considerably revised in the coming months.
The healthcare sector continues to be one of the few areas of job growth in the sputtering economy. Since the start of the recession in December 2007, healthcare employment has grown by 902,000 jobs, while total nonfarm employment has fallen by 7.2 million, BLS data show.
The larger U.S. economy gained 216,000 jobs in March but the nation's jobless rate was little changed at 8.8% for the month, with 13.5 million people unemployed. The number of long-term unemployed -- people jobless for 27 weeks or longer – was 6.1 million, an increase over the 6 million long-term unemployed reported in February, as their ranks increased from 43.9% to 45.5% of the unemployed, BLS preliminary data show.
The federal government’s long-awaited proposed rules governing accountable care organizations have received guarded and mixed reviews from healthcare providers, who were still reading through the 490-page proposal in the hours after its recent release.
Most groups issuing statements about the new rules have professed their support for the concept of ACOs, but say they will reserve judgment until after reading through the implementation details.
“This is an historic effort among government agencies to achieve the goal of better coordinated care," says Linda Fishman, senior vice president for Policy at the American Hospital Association. “It provides a path forward to provide accountable care and supports the direction that the hospital field is already moving toward better coordinated care for patients. However, it does not go nearly far enough to eliminate the barriers to clinical integration among caregivers.”
Jeremy A. Lazarus, MD, speaker of the American Medical Association House of Delegates, reaffirms that “ACOs offer great promise for improving care coordination and quality while reducing cost, but only if all physicians who wish to are able to lead and participate in them. For this to happen, significant barriers must be addressed, including the large capital requirements to fund an ACO and to make required changes to an individual physician's practice, existing antitrust rules and conflicting federal policies.”
America’s Health Insurance Plans President/CEO Karen Ignagni offers the same concern about the details in the implementation. “We remain concerned that ACOs could accelerate the trend of provider consolidation that drives up medical prices and result in additional cost-shifting to families and employers with private coverage,” Ignangni says.
William F. Jessee, MD, president/CEO of the Medical Group Management Association, says the “complexity” of the ACO proposal was “significant” and warranted detailed review. “With multiple agencies proposing rules on the same topic, physician practices need to thoroughly examine how participation in ACOs may affect their practice operations,” Jessee says. “MGMA and our members will develop specific feedback to CMS and the other agencies to ensure that any overly restrictive or administratively burdensome requirements are addressed so this well-intended concept can become a practical reality."
The Obama Administration has said that ACOs could save Medicare as much as $960 million over three years. Before the proposed rule is finalized, however, the Centers for Medicare & Medicaid Services will review all comments from the public and may make changes to its proposals based on those comments, the Department of Health and Human Services said.
HHS Secretary Kathleen Sebelius expressed confidence that ACOs would put patients and their doctors “in control” of their own healthcare. “For too long, it has been too difficult for healthcare providers to work together to coordinate and improve the care their patients receive,” Sebelius said. “That has real consequences: patients have gaps in their care, receive duplicative care, or are at increased risk of suffering from medical mistakes. Accountable care organizations will improve coordination and communication among doctors and hospitals, improve the quality of the care their patients receive, and help lower costs.”
The Medicare Shared Savings Program initiated under the Affordable Care Act will reward ACOs that lower healthcare costs while meeting performance standards on quality of care and patients’ need.
Under the proposal, ACOs – teams of doctors, hospitals, and other healthcare providers and suppliers working together – would coordinate care for patients with Medicare. To share in savings, ACOs would meet quality standards in five key areas:
Patient/caregiver care experiences
Care coordination
Patient safety
Preventive health
At-risk population/frail elderly health.
The proposed rules also include protections to ensure patients do not have their care choices limited by an ACO, HHS said.
If ACOs save money by improving access to primary care so that patients can avoid a trip to the emergency room, for example, the ACO can share in those savings with Medicare. ACOs that do not meet quality standards cannot share in program savings, and over time, those who do not generate savings can be held accountable.
“An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, MD, CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”
All Children's Hospital in St. Petersburg, FL is the first US hospital outside of the Baltimore/Washington DC area to join Johns Hopkins Medicine, the hospitals have announced.
The non-cash transaction formally integrating ACH into JHM took place eight months after the two organizations signed a letter of intent.
"This is a momentous occasion -- the beginning of a new chapter in the history of All Children's Hospital," says Gary Carnes, president/CEO of All Children's Health System. "The goal has always been to become a national leader--not only in clinical care, but also in teaching and research to benefit future generations of children in Florida and beyond. As part of Johns Hopkins Medicine, All Children's value as a key community asset will increase exponentially."
Ronald R. Peterson, president of The Johns Hopkins Hospital and Health System and executive vice president of JHM, said: "Integrating with such an outstanding pediatric medical center as All Children's Hospital offers benefits that will extend far beyond our respective campuses."
Under the terms of the integration agreement, ACH retains its name. Donations made to the Hospital's Foundation remain for the benefit of ACH. Leadership and day-to-day operation of the 259-bed freestanding pediatric hospital and outreach facilities in eight west Florida counties are not expected to change. ACH retains its voluntary medical staff and physician organizations, including those University of South Florida physicians practicing at ACH. The University and ACH will continue the USF Residency Program through 2014, with the possibility of extending beyond that under discussion.
Board governance structure ensures that local community leaders continue oversight of ACH as majority members of the board of trustees. The chairman of the board of ACH will be a member of Johns Hopkins Medicine and members of the ACH board will be offered opportunities to serve on JHM and JHHS committees.
ACH is the only pediatric hospital on Florida's West Coast and one of only two hospitals in the state totally devoted to children's care. ACH draws patients from throughout Florida, 50 states and 36 countries, with specialized staff, services and facilities, including heart transplantation, blood and marrow transplantation, pediatric trauma services and one of the largest neonatal intensive care programs in the southeast. The hospital is part of the billion-dollar All Children's Health System, with more than 2,800 employees on its main campus and 10 outreach centers in west central Florida.
Hospitals can reduce life-threatening bloodstream infections in children with peripherally inserted central venous catheters by removing the devices as early as possible, according to a Johns Hopkins Children's Center study in the journal Clinical Infectious Diseases.
The study, believed to be the largest of its kind in pediatric patients, analyzed predictors of catheter-related bloodstream infections among 1,800 children treated at Hopkins over six years. The children cumulatively underwent more than 2,590 catheter insertions, which resulted in a total of 116 infections.
One potent predictor of infection was length of use, the researchers found. Children whose devices remained in for three weeks or longer were 53% more likely to get a bloodstream infection, compared with those with shorter catheter times. Children who got the catheters to receive IV nutrition were more than twice as likely to get an infection as children who had the devices placed for other reasons, the study found.
The findings of the study underscore the need for a tailored approach to each patient while at the same time following standard infection prevention guidelines, the study's authors said. "Clinicians should evaluate each patient's condition daily and weigh the risk of leaving the device in against the risk of removing it by asking a simple question 'Does this child need a central line for another day?'" says senior author Aaron Milstone, M.D., M.H.S., an infectious disease specialist at Hopkins Children's.
No matter the length of PICC use, the first line of defense against bloodstream infections should always be simple precautions that include rigorous hand-washing before handling the line, regularly changing the dressing that covers the PICC line, and periodically changing the tubes and caps attached to it, the researchers said.
"Even when clinicians follow meticulously basic rules of catheter insertion and maintenance, the risk of infection is never zero," Milstone said. "Reducing the time a child has a PICC is one extra step to minimize that risk."
Researchers found an 80% higher risk of bloodstream infections among children in the ICU than in regular units. However, the study also showed that more than 30% of all infections occurred in children outside of the ICU. Twenty-two percent of infections occurred after patients left the hospital, the researchers found, a finding that points to the importance of educating both parents and home-based caregivers on ways to prevent infections at home.
"Children in intensive care have more severe disease and often require catheters, but it is critical that we remain vigilant about patients with perceived 'lower risk' outside of intensive care, and indeed those outside of the hospital, because they are not immune to infections," said lead investigator Sonali Advani.
