Use systematic approach to identify at-risk patients

Make sure preventive protocols are applied

As the Centers for Medicare & Medicaid Services (CMS) moves to strengthen the tie between quality of care and hospital reimbursement, hospitals should take a systematic and universal approach to identifying patients at risk and preventing hospital-acquired conditions for all patients and not just those covered by Medicare, says Leslie Schultz, RN, NEA-BC, PhD, CPHQ, director, knowledge transfer for Premier Inc.

"Health insurers often develop reimbursement policies that mirror Medicare's policies, so it's important that hospitals utilize evidence-based protocols, tools, and resources to prevent these hospital-acquired conditions for all patients instead of segmenting and identifying certain patient populations for the initiatives," she adds.

The case manager's role in preventing hospital-acquired conditions depends on how the organization is structured, Schultz points out.

"One of the roles of case managers is to make sure nothing slips through the cracks. Case managers should understand how they can support the physicians and other members of the care team in managing the care of the patient," Schultz says.

If they are involved in assessing patients before admission, they should identify patients who are at risk and make sure that the protocols are deployed, she says.

Some of the conditions that must be documented if they are present on admission are relatively predictable, points out Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing, Yoakley & Associates.

For instance, if a patient is coming from a nursing home, that should trigger the physicians and nurses to determine if there is a skin breakdown.

Safety is not a team effort

Patient safety is not the responsibility of just one person or one department, Larrance points out.

"The entire team, including case management, should own the issue of patient safety. Maintaining a safe environment for patients — whether it's hand washing and other sterile techniques, recommended prophylaxis, or getting up and ambulating — is just good clinical practice," Larrance says.

"Case managers need to be part and parcel of the interdisciplinary team. Their role is coordination of care and planning for discharge, but they also can play a role in supporting the clinical areas in their processes as well," says Joanna Malcolm, RN, BSN, BSN, senior consultant for Pershing, Yoakley & Associates.

For instance, Malcolm worked at a hospital where the case management team worked with the infectious disease coordinator on a project to reduce central line infections.

"The case manager's role was mainly tracking and making sure the dates were documented in the system when the catheters were put in and taken out. It was a team effort. Every discipline played a role in the project," she says.

Case management departments should have a good communication mechanism to educate staff about new rules and regulations, whether they're regulations from CMS or commercial payers, Malcolm adds.

"Everybody needs to know what regulations the hospital must follow. People are busy trying to do their day-to-day jobs and often don't have the time to keep up with changes in the rules and regulations, "she says.

Case managers should collaborate with nursing and other providers to help avoid hospital-acquired conditions, Schultz points out.

For instance, in the case of frail patients who are at risk for pressure ulcers, the case manager should ensure that a nutritional consultation is ordered and completed in a timely fashion. They should be concerned with whether a patient might benefit from a special surface or specialty bed to reduce the risk of developing a pressure ulcer, she adds.

"Some of the hospital-acquired conditions, such as DVT after hip and knee replacement surgery, can be avoided with good clinical preventative types of processes. There are evidence-based protocols that should be implemented at the appropriate time following surgery to prevent the development of thrombosis," Larrance says.

Prophylaxis should be on admission order set

In the case of patients who are having hip or knee replacement surgery, case managers should know up front that the person is being admitted and ensure that prophylaxis against deep vein thrombosis and pulmonary embolism is included on the admission order set, Schultz adds.

"There is a lot of good evidence about effective venothromboembolism prophylaxis in orthopedic surgery. It's a matter of standardizing the care and ensuring that everybody on the treatment team knows the treatment plan," Schultz says.

The new focus on glycemic control, especially in people who have not been diagnosed as diabetic, will be more of a challenge, Schultz points out.

"Traditionally, in medicine, we didn't worry about a blood sugar level of 200, but the reality is that when blood sugars are at 200 or higher, the body's immune response doesn't work properly and patients are more at risk to develop an infection postoperatively. Putting people on insulin drips perioperatively and frequent blood glucose checks, which may mean more finger sticks postoperatively, is absolutely the right thing to do in the long run. Patients with a blood sugar level of 100-120 have better outcomes," she says.

However, she cautions, this doesn't mean that hospitals should perform a hemoglobin A1C test on everybody who comes in.

"This may seem daunting, but there are hospitals which are being proactive in the immediate postoperative period and succeeding at avoiding problems caused by poor glycemic control," she says.