Make patient the focus in meeting CMS regs

Use new requirements to leverage administration

Infection preventionists should continue to make patients their medical and moral compass amid a tightening regulatory environment that includes reimbursement reductions.

Indeed, IPs can use new regulatory demands by the Centers for Medicare & Medicaid Services (CMS) to gain resources and program support from administration and hospital boards, said Tammy Lundstrom, MD, JD, a veteran health care epidemiologist and chief medical officer at Providence Park Hospitals in Novi, MI.

"Focus on the patient," she emphasized. "If we always go back to the patient we will make the right decision. Focus on what is what is best for that patient that day. We need to really go back to that and make [decisions based] on what is best for the patient and not necessarily on what we can get paid for and what we won't."

As of Oct. 1, 2008, the CMS has stopped reimbursing for complications associated with certain "preventable" conditions, including the most common health care-associated infection: catheter-associated urinary tract infections (CA-UTIs.)

"Some of the facilities when this first came out said we are going to culture all patients on admission to prove that the UTI was present on admission," Lundstrom said recently in Washington, DC, at an APIC meeting on the CMS changes. "We have a large number of patients with asymptomatic bacteriuria. If we culture for no reason, we are going to get bacteriuria. We all know this from doing UTI surveillance."

A threat to patient safety

That means that an effort to reduce subsequent costs — by showing the condition was not acquired in the hospital and therefore should be reimbursable — actually could endanger patient safety. If patients start testing positive for asymptomatic bacteriuria on admission, the inclination among caregivers will be to provide treatment, she said.

"Most patients don't have a catheter present on admission, so you are adding additional dollars and unnecessary tests for the patients as well as the possibility of unnecessary treatment with antibiotics," Lundstrom said. "That will increase [drug] resistance and increase the Clostridium difficile risk. These are not insignificant risks for the patient, so this approach is out in our facility."

A better approach is to develop a checklist for appropriate indications for placement of urinary catheters, she added. "Educate everybody — nurses, physicians, PAs, medical students, and residents," she said.

By the same token caregivers most know indications for catheter removal so they do not seed infections by being left in indefinitely. Focusing on the patient and preventing the infection essentially takes the reimbursement issue out of the equation, she says.

"The [hospital] board came to me and said, 'How much are we losing on UTIs every year?' and I said, 'I don't care,'" Lundstrom told conference attendees. "I don't care because that does not go with our principle of focusing on the patient. So we are going to report the percentage the catheter insertions that have approved indications and we are going to get to 100%. We are going to report that the percentage of catheters that were removed on the day that indications for use were not longer met — and that is going to be 100%."

Reporting such data underscores the focus on the patient and the fact that not all HAIs are preventable even if all standards of care are met, she said. "If a patient develops a UTI that actually needed a catheter [then] I couldn't have done anything to prevent it," she said. "I provided the right care to the patient at the right time. The fact that I didn't get paid when it happened is immaterial. It is all about the patient. In terms of my day-to-day work, this doesn't impact what I do in infection control in my program, other than I need to be aware of it and use it as an opportunity to talk about prevention."

Indeed, going point-by-point through CMS regulation 482.42 (Condition for Participation: Infection Control), Lundstrom emphasized that IPs should leverage such requirements to strengthen their programs. The CMS regulation requires that there be an "active program for the prevention, control and investigation of infections and communicable diseases," which could be read to do housewide surveillance for everything.

"Does this mean you can not do targeted surveillance? No, "Lundstrom emphasized. "An 'active hospitalwide program' doesn't mean that you can't do targeted surveillance."

Still, the CMS requires that hospitals have to have a mechanism in place to identify and monitor HAIs and communicable diseases occurring in any location and department, she added.

"You don't necessarily need to target everything," she said. "You might have microbiology logs that you review from every area that are available for you to scan. You might develop infection control 'deputies,' unit-based infection control personnel, or clinic based IPs to see what is coming into your clinics. It could be syndromic surveillance of health care workers in terms of respiratory and GI illness. You have to consider [housewide] as part of your risk assessment, but you don't have to monitor everything all of the time."

The CMS also requires a comprehensive prevention and control plan for multidrug-resistant organisms (MDROs). "Do you have to doe separate MDRO risk assessment? No," Lundstrom said. "You're overall risk assessment should incorporate MDROs, but this does not mean you have to have a separate written plan for MDROs."

CMS calls for a 'multidisciplinary effort,' giving impetus to efforts to involve physicians and pharmacy in the MDRO program. "It is very important to have a pharmacist as a member of your team to be able to educate physicians on what the resistance patterns are in the facility and what should they be using as empiric antibiotic choices," she said.

Get the board on board

IPs should engage their hospital boards and administration, presenting data and showing prevention efforts. "You've got [a CMS] standard — use it with your administrator to get the attention of the board," she said. "You can use the CMS standards to help you promote your program."

For example, CMS standard 482.42(a) under organization and polices says the hospital "must have adequate resources devoted to the program." The resources should not be based on census alone but also consider scope, complexity and patient characteristics, she emphasized.

"[Say], here's what we did, but here's what we could accomplish with more infection control resources," Lundstrom advised. "Use these standards freely to get the ear of the board and the ear of administration. Get the resources you need to be able to do even more for patient safety and quality. The most important value of this to me is that it galvanizes everybody in the facility to work in the same direction."

The regulatory era of infection prevention will probably only intensify because patients and their advocates are increasingly demanding action to prevent HAIs. In a personal aside, Lundstrom said the perspective of the patient is understandable if you have a loved one hospitalized. Not known for being shy, Lundstrom is both a physician and an attorney. Yet, she admitted to the audience, she realized how hard it was to enforce hand hygiene when her son was recently hospitalized after a snowboarding accident. "I actually recognized — even as a health care worker — it's very difficult to really remind other health care workers who come into the room to wash their hands."

Undaunted, she took a seat by the door — between her son and the alcohol gel dispenser. "There was a narrow entry way into the room and I was sitting right [by] the alcohol hand gel dispenser," she said. [I put] my leg out like a swing gate when they came into the room and pointed to the hand gel. It was really hard to force myself to remind people. I was thinking, 'Well, what if they did it outside the room?' But I just put up the 'gate' near the dispenser and they got the hint. One hundred percent of people who touched my child washed their hands — or the gate was not lowered."