For the 30 million Americans living with some form of kidney disease, the current COVID-19 pandemic brings a host of additional challenges not faced by the general population—like a greater risk of developing serious complications if they contract the virus. And for the 500,000 Americans with kidney failure who rely on dialysis treatments to stay alive, these challenges only multiply. Do they follow “stay-at-home” orders and skip their dialysis treatments, or do they risk exposure by going to a dialysis clinic where social distancing is difficult, if not impossible, to enforce? Either decision could have life-threatening consequences.
And what about the procedures to create and maintain the necessary access to their bloodstream that makes dialysis possible? In mid-March, the CMS deemed these procedures “non-essential,” leading to a host of cancelled appointments and operations. Even when CMS reversed its decision days later, the confusion that resulted from the chaos left many physicians, hospitals and patients unsure of which path to follow.
In the United States alone, nearly half a million people currently suffer from end-stage kidney disease and must undergo hemodialysis several times a week. For these patients, the vascular access site is quite literally their lifeline, as it provides direct access to their bloodstream for the life-saving treatments.
Yet due to the current COVID-19 outbreak, procedures to establish these vascular access sites have been deemed “non-essential” elective procedures by CMS and HHS, and nephrologists and vascular surgeons are finding themselves unable to secure operating room time.
Though we must all work together during this crisis to reduce the intense strain on our healthcare system, this decision could have devastating implications for patients with end-stage kidney disease — a group that is already highly vulnerable to potential complications of COVID-19. Limiting access to these procedures will increase reliance on riskier vascular access options that significantly increase patients’ chances of infection, hospitalization and even death. This will only add to the strain on resources as hospitals continue to deal with the outbreak.
With something like 300 million peripheral IV lines sold in U.S. each year – and a failure rate that’s often cited as being 50% – researchers continue to try to understand a problem that’s a daily headache in vascular access and infusion therapy.
Common causes of line failure are dislodgement, infection, thrombosis, phlebitis and occlusion. Peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) tend to be better secured than peripheral IVs, but they are also subject to high failure rates.
In an earlier post, we detailed the advantages that both hospitals and patients gain when non-physician vascular access specialists (VAS’s) are allowed to place central venous catheters (CVCs) and arterial lines. Now a recently published article describes how a vascular access team at a large community hospital in Illinois expanded its scope of practice to encompass these lines.
How the ACA’s Pay-For-Performance Programs Target Catheter-Related Bloodstream Infections
The mainstream media has primarily covered the Patient Protection and Affordable Care Act (also known as the ACA or Obamacare) for how it affects health insurance. But as healthcare insiders, readers of this blog know there’s much more to this groundbreaking piece of legislation — including its provisions aimed at upping healthcare quality and lowering healthcare costs. Many of those provisions affect the practice of vascular access because catheter-related bloodstream infections (CRBSIs) have both quality and cost implications.
Healthcare providers should be taking a close look at these sections of the law because they can affect everything from reimbursements to materials management. Vascular access specialists (VAS’s) should know the provisions, too, because the ACA targets vascular access outcomes.
A recent study found that a central venous catheter (CVC) designed to reduce bloodstream infections totally eliminated them at a hospital in Spain. The antimicrobial CVC also sharply reduced treatment costs related to the infections, compared to the unprotected CVC matched against it. You can read a study summary here.
The antimicrobial CVC in the study was the ARROW® CVC with ARROWg+ard® Technology. The catheter achieves its antimicrobial effect from a protective layer of chlorhexidine and silver sulfadiazine bonded to the catheter’s surface.
The Affordable Care Act (ACA), more commonly known as Obamacare, is 906 pages long. But amidst all that detail are a few driving goals. One of those is something few would argue with: higher quality healthcare at lower cost. That’s also the focus of a new white paper on vascular access.
It’s no wonder the ACA’s authors made that a priority. The U.S. lags behind other industrialized countries on both sides of the quality/cost equation. We have the most expensive healthcare, by far, among industrialized nations, according to both the Organization for Economic Co-operation and Development (OECD) and the healthcare-focused Commonwealth Fund. The U.S. also ranks worse than many of these nations on some measures of quality, including safety.
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.
The U.S. Department of Health & Human Services (HHS) has started to publish, for the first time ever, data showing how hospitals nationwide compare in their rates of central line-associated bloodstream infections (CLABSIs) in their intensive care units (ICUs). The public can view the rates on HHS’ Hospital Compare website when deciding which facility they want to patronize. The data will be updated quarterly, with rates for other infections added in the future.
Will this be a game-changer? It very well might be. It comes on the heels of other incentives the feds have used to get hospitals to lower their CLABSI rates, so the new effort could create a tipping point. Here are the previous initiatives:
* In October 2008, the federal Center for Medicare and Medicaid Services (CMS) ceased reimbursing hospitals for a number of hospital-associated conditions, including CLABSIs, that it considered preventable.
* CMS lowered the financial boom again about two years later. As we reported here, CMS mandated that to get full Medicare payments, hospitals had to report CLABSIs and certain other healthcare-acquired infections (HAIs) on the CDC’s National Healthcare Safety Network (NHSN).
The reporting to NHSN began in January 2011, and it is that data that is being shared on Hospital Compare. Although the reporting is voluntary, most hospitals participate for obvious reasons – it would be unthinkable to suffer lower Medicare payments. By the way, much of the credit for these government crackdowns goes to Consumers Union, which for years has been pushing for action on HAIs through its Safe Patient Project.
Of course, Hospital Compare is going to keep some hospital CEOs up at night.
Undoubtedly, savvy patients will penalize facilities with high CLABSI rates when they go hospital hunting. Some CEOs complain that a simple comparison of CLABSI rates puts their institutions at an unfair disadvantage. We’re sympathetic to that claim in some cases. We’ve worked with several hospitals whose patient populations are unusually vulnerable to CLABSIs.
For example, we’ve written about one well-regarded children’s hospital that nevertheless has much higher-than-usual CLABSI rates because many of its patients suffer from short bowel syndrome and also receive total parenteral nutrition. Both issues significantly increase CLABSI risk.
But note that this hospital was still able to lower its CLABSI rates dramatically by taking several preventive steps, including implementing an alcohol-dispensing disinfection cap called SwabCap® that improves disinfection of IV connectors. Disclosure: (We represent SwabCap’s maker, Excelsior Medical.)
Numerous hospitals that were struggling to reduce their CLABSIs achieved sharp reductions when they adopted the disinfection cap, which smartly addresses the problems with the traditional approach to disinfecting connectors.
So, yes, Hospital Compare will sometimes compare apples to oranges, but hospitals can and should reduce infections by implementing best practices and evidence-based technologies like the disinfection cap.
Average hospital CLABSI rates have dropped some over the years, thanks in part to campaigns by the feds, Consumers Union, and other concerned organizations. Consider, though, that many experts believe CLABSIs can be completely eliminated. If they’re right, there’s still room for improvement.
Having worked previously for the Association for Vascular Access (AVA), last year we began supporting the efforts of AVA’s research and education arm, the Wise Foundation.
AVA and the foundation ended the year on a high note, with the announcement of a major grant from AVA to the foundation. The $50,000 grant, given in honor of AVA’s membership, underlines AVA’s support for the foundation’s mission. The grant also strengthens the foundation’s outreach to other major funders.