Hospital Consult - May 2015
Hospital Access Management - Hospital Case Management - Hospital Employee Health
Hospital Infection Control - Hospital Peer Review - Healthcare Risk Management
Case Management Advisor - IRB Advisor - Medical Ethics Advisor - Same-Day Surgery
Spring Is High Season for C. difficile, Especially in Northeast
AUSTIN, TX – If your hospital is like most, rates of infection with the superbug Clostridium difficile have been elevated over the last few months, compared to other seasons – especially if the facility is located in the Northeast.
That’s according to a new study published recently in the American Journal of Infection Control, which found that over the last decade C. difficile infection rates were highest in the Northeast region of the country and in the spring season for adults but different for children.
To determine that, researchers from the University of Texas College of Pharmacy retrospectively analyzed 2.3 million cases of C. difficile infection (CDI) from 2001-10 and found the highest incidence in the Northeast (8.0 CDI discharges/1000 total discharges), followed by the Midwest (6.4/1000), South (5.0/1000), and the West (4.8/1000).
For adults, infection was most common in the spring (6.2 CDI discharges/1000 total discharges), followed by winter (5.9/1000), summer (5.9/1000) and fall (5.6/1000), the authors note, adding that pediatric CDI tends to be highest in winter and occurs most commonly in the West.
Mortality from the deadly superbug was highest in the Midwest (7.3%), however, and among older adults (9%).
"The peak incidence in the spring could be attributed to increased utilization of antibiotics in winter months," the authors suggest. "Prior studies have found a one to two month lag time between antibiotic exposure and the development of CDI."
According to the national Centers for Disease Control and Prevention, C. difficile has become the most common microbial cause of healthcare-associated infections in U.S. hospitals and costs up to $4.8 billion each year in excess healthcare costs for acute care facilities alone.
The infection caused almost half a million infections in 2011, with at least one recurrence in 83,000 of those patients, according to the CDC. Within 30 days of their initial diagnosis, 29,000 U.S. patients died that year, public health officials add.
Elevating the Heads of Women Post-Partum Improves Respiratory Safety
BOSTON – Here’s a simple way to improve respiratory safety in women who just gave birth: prop them up in bed.
A study published online recently by the journal CHEST suggests an elevated upper body position might improve respiratory safety in women early after childbirth without impairing sleep quality.
Background information in the article notes that pregnancy-related maternal death occurs in 10 to 13 of 100,000 pregnancies and is attributable to anesthesia in 0.8% to 1.7% percent of the cases. A major cause of anesthesia-related maternal death is postpartum airway obstruction.
"Women who sleep with their upper bodies propped up 45 degrees in the days following childbirth can significantly reduce their risk of postpartum airway obstruction, a meaningful symptom of obstructive sleep apnea early after delivery," explained study author Matthias Eikermann, MD, clinical director in the Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital in Boston.
The article notes that while obstructive sleep apnea (OSA) isn’t that common in young women, about 4.9% suffer from the condition, which tends to worsen as pregnancy progresses and continues into the early post-partum period.
For the study, researchers enrolled 55 women during the first 48 hours after delivery. Polysomnography was performed in both non-elevated and 45 degrees elevated upper body position for 30% of the patients. In addition, upper airway cross-sectional area was measured by acoustic pharyngometry in non-elevated, 45 degrees elevated and sitting body positions.
The researchers report that elevation of the upper body significantly reduced apnea-hypopnea index from 7.7±2.2/h in non-elevated to 4.5±1.4/h in 45 degrees elevated upper body position during sleep.
“Moderate to severe OSA (AHI >15/h) was diagnosed in 20% of postpartum patients and successfully treated by elevated body position in half of them,” the authors write. “Total sleep time and sleep architecture were not affected by upper body elevation.”
FDA Proposed Rule Puts Hospital Antiseptics Under Scrutiny
WASHINGTON, DC – How many times a day do you use hand washes and rubs to prevent the spread of infections?
The answer is that you probably do it so often you lose count. You also aren’t likely to give much thought to how safe those products are. The Food and Drug Administration, however, is asking that very question.
The FDA recently issued a proposed rule requesting additional scientific data to support the safety and effectiveness of certain active ingredients used in healthcare antiseptics marketed under the over-the-counter drug monograph.
“Healthcare antiseptics are an important component of infection control strategies in hospitals, clinics and other health care settings, and remain a standard of care to prevent illness and the spread of infection,” said Janet Woodcock, MD, director of the FDA’s Center for Drug Evaluation and Research (CDER). “The FDA recommends that healthcare personnel continue to use these products consistent with infection control guidelines while additional data are gathered.”
So why was the action taken now?
Colleen Rogers, PhD, lead microbiologist in FDA’s Center for Drug Evaluation and Research’s Division of Nonprescription Drug Products, responds that “FDA’s safety standards and our ability to detect and measure antiseptics in the body have evolved since the active ingredients used in these products were last evaluated.”
Because many of these active ingredients have been used for a very long time, Rogers adds in an FDA blog, the available research often does not meet current scientific standards and also does not reflect the way the products are used today.
She said the latest effort is primarily to protect healthcare workers. “As you might imagine, a lot has changed in the practice of medicine since the early 1970s when our review of monograph antiseptics began. These days, antiseptics are being used more frequently – in some cases up to 100 times a day.”
That could result in greater systemic exposure to antiseptic active ingredients than previously thought, according to the FDA.
“In addition, new data and technology to detect these ingredients in body fluids – such as serum and urine – have become available and indicate that systemic exposure to antiseptic active ingredients could occur due to absorption through the skin,” Rogers notes.
The rule covers products marketed as reducing bacteria that can potentially cause disease; the most common active ingredients used in these products are alcohol and iodines. The active ingredients under FDA scrutiny must have been used in healthcare antiseptics that were on the market prior to 1972.
Chlorhexidine gluconate, also a common active ingredient in health care antiseptics, consumer antibacterial soup or consumer hand-sanitizers, is not affected by the proposed rule, however.
The FDA explained that over-the-counter drugs, including antiseptics, are regulated in one of two ways: under an OTC drug monograph or a New Drug Application. The data requests in the proposed rule pertain to OTC monograph health care antiseptics only and will not affect antiseptic products marketed under New Drug Applications.
Hospitals Rack Up Victories Against RACs, But Denials Continue
MADISON, WI – Medicare's recovery audit contractors (RACs) have continued to increase their scrutiny and denials of hospital payment claims in recent years, even though more and more of their actions have been overturned in favor of the hospitals.
According to the American Hospital Association's RACTrac website, hospitals appeal nearly one in four RAC denials with an 85% success in the appeals process.
The overall solution, according to a recent study in the Journal of Hospital Medicine, is RAC reform, including improved transparency in data reporting.
Study authors led by researchers from the University of Wisconsin School of Medicine and Public Health, note that hospitals and patients have grown increasingly concerned about determinations related to observation and inpatient status for Medicare beneficiaries. “Recovery Audit Contractor (RAC) activity alleging improper status, however, has received little attention, and there are conflicting federal and hospital reports of RAC activity and hospital appeals success,” they add.
To shine some light on the situation, the researchers looked at complex Medicare Part A audits at three academic hospitals – the University of Utah Hospital in Salt Lake City, Johns Hopkins Hospital in Baltimore, and University of Wisconsin Hospital in Madison – from 2010 to 2013.
Results indicate that, of 101,862 inpatient Medicare encounters, RACs audited 8%. Overpayment was alleged in 31.3% of those audited cases, and hospitals disputed 91.0% of the overpayments.
“There was a nearly three-fold increase in RAC overpayment determinations in two years, although the hospitals contested and won a larger percent of cases each year,” the authors point out.
The overpayment determinations didn’t contest the need for care delivered, the study explains, but that the care should have been delivered under outpatient, not inpatient, status.
The study finds that about a third of settled claims were decided in the discussion period; those favorable decisions for the hospitals are not reported in federal appeals data.
In addition, nearly half (951/1935) of settled contested cases were withdrawn by the hospitals and rebilled under Medicare Part B to avoid the lengthy – a mean of 555 days – appeals process. The healthcare facilities employed an average of 5.1 full-time staff in the audits process, according to the study.
The original inpatient claims were then counted as improper payments recovered by the RAC.
While hospitals also lost appeals 0.9% of the time by missing a filing deadline, there was no reciprocal case concession when the appeals process missed a deadline, study authors emphasize.
This webinar will discuss the newly published infection control deficiencies along with detailed information on why hospitals were found to be out of compliance.
Topic: The Final CMS Worksheet on Infection Control
Speaker: Sue Dill Calloway, RN, MSN, JD
Date: June 3, 2015
Time: 1-2:30 PT & 4 – 5:30 PM ET
Accreditation: 1.5 CNE Credits Available
