At the recent annual meeting of the Association for Vascular Access (AVA), speaker Leslie Schultz, Director of the Safety Institute at Premier, Inc., introduced a provocative idea. Vascular access professionals, she said, can help their employers avoid the substantial financial penalties they face for high rates of central-line-associated bloodstream infections (CLABSIs).
Schultz was referring to the substantial penalties mandated by the Affordable Care Act (ACA), popularly known as Obamacare. The ACA tries to improve healthcare and lower costs by penalizing hospitals that trail most of their peers in preventing infections.
Schultz has a keen sense of the contributions nurses can make to minimizing a hospital’s CRBSI rate. In addition to her role at Premier, she is an RN as well as a Ph.D. Premier’s Safety Institute offers free information, tools, and resources to advance patient safety.
Before diving into how vascular access professionals can leverage their expertise to reduce CRBSIs and the associated penalties, here’s some crucial background. One of the central goals of the ACA is to use financial incentives to change the dynamics of U.S. healthcare, so that quality of care is rewarded more than quantity of care.
Since nearly all hospitals and many other providers receive much of their revenue from Medicare, the ACA directs the federal Centers for Medicare and Medicaid Services (CMS) to use Medicare-related carrots and sticks (mostly sticks) to improve healthcare quality and reduce healthcare quantity. Besides serving patients better, it is hoped the changes will reduce healthcare costs.
Here are some examples of the ACA’s carrots and sticks related to CLABSIs:
*To receive their full payment update from CMS, hospitals must report certain infections including central-line associated bloodstream infections to the CDC’s National Healthcare Safety Network (NHSN). That information is then made public via CMS’ Hospital Compare website, with the hope that patients will reward better-performing hospitals with their patronage.
*Starting in FY 2015, CMS will withhold 1% of Medicare payments for hospitals “that rank in the lowest-performing quartile of hospital-acquired conditions.” A hospital’s CLABSI rate is a key component of the index used to determine which hospitals to penalize.
*Starting in FY2015, CMS implements its Inpatient Value-Based Purchasing (VBP) program. This is a budget-neutral policy where some hospitals must fail to meet targets for a bonus to be generated for others. Importantly, it puts 1.5% of a hospital’s base operating payments at risk – with rewards for achievement or improvement.
One percent here and there may not sound like much — but when a hospital’s Medicare revenues are in the millions, the penalties can be six figures at minimum.
So what can a vascular access professional do to make sure their employers are not among the penalized? The most important thing is be meticulous about their vascular access care and also support their hospital in requiring catheter insertion and maintenance practices recommended by the CDC and such authoritative organizations as the Infusion Nurses Society (INS), the Society for Healthcare Epidemiology of America (SHEA), and the Infectious Diseases Society of America (IDSA).
But even following these parties’ basic guidelines is not always enough. As INS and SHEA/IDSA have themselves recognized, hospitals that have unsatisfactory CRBSI rates should take additional steps. According to those organizations, those steps include using:
* An antimicrobial/antiseptic catheter. This is also recommended by the CDC. We note that catheters such as the ARROW® PICC with Chlorag+ard® Technology and the ARROW® JACC central venous catheter with Chlorag+ard® Technology are antithrombogenic as well as antimicrobial. (Both catheters are made by Teleflex, Inc., a Dowling & Dennis client. Teleflex also sponsored Schultz’s talk.)
* A chlorhexidine gluconate (CHG) gel pad or foam disk at the catheter insertion site. These devices secrete the broad-spectrum antiseptic CHG at the site for a week or more, protecting the IV line from invasion by bacteria from the patient’s skin.
SHEA/IDSA also recommends that hospitals with high CLABSI rates use a disinfection cap. One such device, called SwabCap, improves disinfection of the hubs of IV needleless connectors.
Clinicians are well-positioned to advocate for use of the these devices if their employers are not already deploying them. As Schultz puts it: “When you look at the vascular access professionals, and if you even look at AVA’s home page, you are about evidence-based practices, standardization, demonstrating competencies and efficiencies. You are about avoiding harm. You are in the sweet spot of where hospitals are going to face pain under the Affordable Care Act. You are an answer.”
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Very interesting reading. I am glad that there have been measures taken to incentivize healthcare facilities to do what’s right by their patients. It’s sad that money is the motivator but desperate times call for desperate measures.
While two facets of the bundle are mentioned here, coated catheters and a swab cap device, I would like to point out additionally that it takes ALL of the central line bundle to cut CLABSIs. If every nurse used proper hand hygiene and scrubbed the needless connector as well as the hub upon changing of the connector additionally allowing for dry time before accessing, we would be living in a different world.
How about the fact that many bedside Picc teams still place lines by themselves in a room with only the inserter and the patient? Name one other sterile invasive procedure done anywhere in the US with only one person in the room? How can one maintain sterility alone? It takes more than one set of eyes to assure there isn’t a break in technique. We all know the reason … Money. Yet we will fork over large amounts of it on penalties and unnecessary devices to attempt to reduce line infections.
Just ask Sophie Harnage of Sutter Roseville Medical Center in Roseville California who hasn’t had a Picc line infection in 7 years. They do not use coated catheters incidentally. They have such an all inclusive bundle/over and above the bundle process, that it has proven significantly effective in iradicating CLABSI.
I challenge each Vascular Access Team to read Sophie’s article and consider adapting their process or come up with one of your own.
With so much focus on healthcare cost and reimbursement perhaps a good back to the basics model would be prudent.
Excellent points, Renee, and thanks for posting here.