Penalizing hospitals for never event infections is ineffective

I told you so.

Three months ago, I blogged about the Medicare (CMS) “never events” list, diagnoses that Medicare will no longer reimburse hospitals for. In Medicare’s eyes, these diagnoses are totally preventable, should never happen and will not be reimbursed. I pointed out that several were in fact not 100% preventable despite any institution’s best efforts, and the rates of many of these occurrences would not fall to zero.

Now the esteemed New England Journal of Medicine has published a paper which confirms what I wrote back in July. Its 13 authors compared rates of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), two of the diagnoses on the “never events” list, with ventilator-associated pneumonia, a disease not on the list, as a control.

After reviewing data from 398 hospitals from before and after the establishment of the new Medicare rules, they found that quarterly rates of all three infections did not change and concluded that the “never events” policy was ineffective. The senior author of the study then tweeted “Our paper in NEJM – CMS non-payment policy didn’t change infection rates. Do we need much stronger penalties?”

My answer to that question is “No.”

Penalizing hospitals did not work because we may have reached the lowest possible rates of infection already. Some infections will occur no matter what steps are taken. We are dealing with human patients and human care-givers. Perfection is not likely to happen.

Many people erroneously believe that all CLABSIs can be prevented with the implementation of strict sterile precautions when catheters are inserted. That has lowered infection rates but not to zero. Why not? In addition to the technique of insertion, CLABSIs can result from other factors. Solutions may become tainted. The integrity of the IV line itself may be violated during the administration of medications through the line. The dressing covering the line may loosen and allow bacteria to enter the puncture site. Patients may be immunosuppressed and unable to overcome even the slightest hint of contamination. Or maybe it’s just bad luck.

CAUTIs are also not totally preventable. Despite a major push to remove urinary catheters as soon as possible, some patients need them for days to weeks for many reasons. For example, there are patients who simply cannot urinate on their own due to old age, dementia, coma, paralysis, etc. Critically ill patients with marginal urine outputs need urinary catheters for monitoring. Patients who are incontinent of stool may contaminate their catheters despite the best nursing care.

No, much stronger penalties will not work.

How about if we simply decide what is an acceptable rate for these infections and aim for that?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • lauramitchellrn

    I never thought this was a particularly good idea, but what do I know? Penalizing hospitals and providers for things that essentially fall into the “shit happens” category is counterproductive. We can mitigate and minimize a lot of things, but sometimes the confluence of events are such that we can’t prevent something, but have to deal with it after it happens. It sounds like this particular “rule” was made by people far removed from the clinical environment and who are making judgments based on actuarial rather than clinical methods.

  • Doug Capra

    You make some good points. But let’s look at this another way using two examples: First, hand washing. When hospitals reach 100 percent caregiver hand washing, then we can say we’re really doing everything we can about infections. Are we there yet? How close are we? Why are some hospitals still having so much trouble with this? Some hospitals are or are considering using technology and devises attached to caregivers to assure caregivers wash their hands regularly. If this is not a problem, why would that be necessary? Second example, patient falls. By making sure that some staff members checks each patient room at least every 15 minutes and asks if the patient needs to use the bathroom, you help assure that the patient won’t need to go and try to get there him/herself. This frequent checking gives merit to them just being told how important it is to ask for help in these situations. It shows caregivers walking the talk. Granted, some patients are stubborn and will try to go on their own anyway — but proactive actions like these help mitigate the problem — and we’re still a significant distance away from saying we’re really doing all we can to solve these problems.

  • Skeptical Scalpel

    Thanks for the comments. I agree that a lot of these rules appear to have been thought up by people who must not be clinicians. I don’t quite get the analogy between handwashing or falls and readmissions. Readmissions are much more complex than handwashing or falls.

    Also, people will never be 100% compliant with handwashing. It would be nice but humans don’t function at a level of 100% perfection. Similarly with falls, who says checking every 15 minutes will prevent them? And what hospital or nursing home has enough personnel to check patients every 15 minutes?

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