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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