Common Hospital-acquired Conditions Research Articles

Defects in Value Associated With Hospital-Acquired Conditions: How Improving Quality Could Save U.S. Healthcare $50 Billion.

Hospital-acquired conditions in the United States are considered avoidable complications but remain common statistics reflecting on health system performance and are a leading cause of patient fatality. Currently, over 3.7 million patients experience a hospital-acquired condition in the United States each year, which costs the U.S. healthcare delivery system an excess of $48 billion. Evidence-based clinical practice guidelines for common hospital-acquired conditions (e.g., infections, falls, pressure injuries) to reduce risk to the patient. In each of these instances, preventing the outcome with these guidelines costs less than treating the outcome, in addition to keeping the patient safe from harm. By applying the framework of defects in value to hospital-acquired conditions, we estimate that U.S. health systems could avert this $48 billion in spending on treating harmful hospital-acquired conditions; more so, these systems of care could recuperate over $35 billion after investing proportionally in a system that delivers greater quality by preventing hospital-acquired conditions over treating them. Currently, the Centers for Medicare and Medicaid Services only withholds reimbursements for hospital-acquired conditions and penalizes health systems with high rates of these outcomes. However, payers do not offer any reward-based incentives for hospital-acquired condition prevention. A series of policy and health system solutions, including tracking of hospital-acquired condition rates in electronic health records, identifying centers of excellence at reducing rates of harm with the use of clinical practice guidelines, and rewarding them monetarily for reduced rates could create equal-sided risk and opportunity to engage health systems in improved performance.

Dashboard Design to Identify and Balance Competing Risk of Multiple Hospital-Acquired Conditions.

Hospital-acquired conditions (HACs) are common, costly, and national patient safety priority. Catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure injury (HAPI), and falls are common HACs. Clinicians assess each HAC risk independent of other conditions. Prevention strategies often focus on the reduction of a single HAC rather than considering how actions to prevent one condition could have unintended consequences for another HAC. The objective of this study is to design an empirical framework to identify, assess, and quantify the risks of multiple HACs (MHACs) related to competing single-HAC interventions. This study was an Institutional Review Board approved, and the proof of concept study evaluated MHAC Competing Risk Dashboard to enhance clinicians' management combining the risks of CAUTI, HAPI, and falls. The empirical model informing this study focused on the removal of an indwelling urinary catheter to reduce CAUTI, which may impact HAPI and falls. A multisite database was developed to understand and quantify competing risks of HACs; a predictive model dashboard was designed and clinical utility of a high-fidelity dashboard was qualitatively tested. Five hospital systems provided data for the predictive model prototype; three served as sites for testing and feedback on the dashboard design and usefulness. The participatory study design involved think-aloud methods as the clinician explored the dashboard. Individual interviews provided an understanding of clinician's perspective regarding ease of use and utility. Twenty-five clinicians were interviewed. Clinicians favored a dashboard gauge design composed of green, yellow, and red segments to depict MHAC risk associated with the removal of an indwelling urinary catheter to reduce CAUTI and possible adverse effects on HAPI and falls. Participants endorsed the utility of a visual dashboard guiding clinical decisions for MHAC risks preferring common stoplight color understanding. Clinicians did not want mandatory alerts for tool integration into the electronic health record. More research is needed to understand MHAC and tools to guide clinician decisions.

Predictors of serious, preventable, and costly medical complications in a population of adult spinal deformity patients

Background ContextIn 2008, the Centers for Medicare and Medicaid Services (CMS) established a list of hospital-acquired conditions (HACs) with significant deleterious effects on both patients and providers. Adult spinal deformity (ASD) surgery is complex and highly invasive, and as such may result in significant morbidity including these HACs. PurposeIdentify predictors for developing the most common HACs among adult spinal deformity (ASD) patients undergoing corrective surgery. Study Design/SettingRetrospective analysis. Patient SampleOne thousand one hundred and seventy-one ASD patients. Outcome MeasuresHACs, Health-Related Quality of Life scores(HRQLs), Reoperation, Integrated Health State (IHS) MethodsASD pts undergoing surgery (>18 years, scoliosis ≥20°, SVA ≥5 cm, PT ≥25° and/or TK >60°) with complete data at BL and up to 2 years post-op were included. Patients were stratified by presence of >1 HAC, defined as at least one superficial/deep SSI, UTI, DVT, or PE within a 30-day post-op window. Random forest analysis generated 5,000 Conditional Inference Trees to compute a variable importance table for top predictors of HACs. An area-under-the-curve (AUC) methodology compared normalized HRQL scores between groups to determine an IHS with 2-year follow-up. ResultsTotal of 1,171 pts (59.8 years, 76.2%F, 28.1kg/m2) underwent corrective ASD surgery, with 1,053 pts in the non-HAC group and 118 in the HAC group. Of these pts, 25.4% had UTI, 15.4% DVT, 19.2% superficial SSI, 20.8% deep SSI, and 19.2% PE. HAC pts were on average older (63.5 vs 59.3, p=.004) and more often frail (51.3 vs 39.7%, p=.021) than non-HAC pts. Postop LOS and reoperation were most associated with HAC groups: [1] LOS >7 days [2] reoperation. Patient-related predictors of HACs were [3] age >50 yerr, [4] frailty, and [13] BMI >31. Procedure-related predictors of HACs were [5] operative-time >405 minutes, [6] levels fused >9, EBL >1450 mL, and [11] decompression. BL radiographic predictors were [7] PT >20°, [9] PI-LL>6°, [10] TL Cobb angle >15°, [12] SVA C7-S1 >29 mm. No differences were observed between groups with regards to IHS ODI (0.73 vs 0.74, p=.863), SRS (1.3 vs1.3, p=.374), NRS Back (0.6 vs 0.6, p=.158). HAC had higher rates of reoperation than non-HAC (0.08 vs 0.01, p=.066), and any HAC within 30-days of index was a significant predictor of reoperation (OR: 2.448 [1.94–3.09], p<.001). ConclusionsIn a population of ASD patients, HACs were associated with length of stay, reoperation, age, and frailty. Radiographic parameters such as pelvic tilt >20°, PI-LL >6°, & SVA >29 mm also increased odds of HACs, and should raise postoperative awareness for HAC development.

Hospital-acquired conditions occur more frequently in elective spine surgery than for other common elective surgical procedures

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called “never events.” The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons’ NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery.

Hospital-Acquired Conditions after Liver Transplantation

Hospital-acquired conditions (HACs) are used to define hospital performance measures. Patient comorbidity may influence HAC development. The National Inpatient Sample database was used to investigate HACs for the patients who underwent liver transplantation. Multivariate analysis was used to identify HAC risk factors. We found a total of 13,816 patients who underwent liver transplantation during 2002-2014. Of these, 330 (2.4%) had a report of HACs. Most frequent HACs were vascular catheter-associated infection [220 (1.6%)], falls and trauma [66 (0.5%), catheter-associated UTI [24 (0.2%)], and pressure ulcer stage III/IV [22 (0.2%)]. Factors correlating with HACs included extreme loss function (AOR: 52.13, P < 0.01) and major loss function (AOR: 8.11, P = 0.04), hepatopulmonary syndrome (AOR: 3.39, P = 0.02), portal hypertension (AOR: 1.49, P = 0.02), and hospitalization length of stay before transplant (AOR: 1.01, P < 0.01). The rate of HACs for liver transplantation is three times higher than the reported overall rate of HACs for GI procedures. Multiple patient factors are associated with HACs, and HACs may not be a reliable measure to evaluate hospital performance. Vascular catheter-associated infection is the most common HAC after liver transplantation.

Clinical Impact and Economic Burden of Hospital-Acquired Conditions Following Common Surgical Procedures.

Retrospective review of prospectively collected data. To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures. HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety. Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database. Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P < 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ± 0.04 days longer (P < 0.001) and payments were $8893 ± $148 greater (P < 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P < 0.001). Adjusted additional LOS was 0.44 ± 0.02 and 0.38 ± 0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ± 0.11 days LOS and $4842 in payments (P < 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively). HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not. 3.

Wednesday, September 26, 2018 3:35 PM – 5:05 PM How to Avoid Complications: 98. Hospital-acquired conditions occur more frequently in elective spine surgery than for other common elective surgical procedures

BACKGROUND CONTEXT Hospital-acquired conditions (HACs) have significant deleterious effects on patients and providers. These events have been the focus of recent policy initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. PURPOSE To determine the rates of the three most common HACs that occur within 30-days postoperatively for spine surgeries and compare them to other common surgical procedures. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. PATIENT SAMPLE A total of 647,878 patients from a national database undergoing common surgical procedures. OUTCOME MEASURES Rates of the three most common HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), and urinary tract infection (UTI). These rates were compared between patients undergoing spine surgery versus other surgical procedures. METHODS Patients over 18 years who underwent elective spine surgery were identified in the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. These patients were stratified by whether they experienced at least one HAC and then compared to those undergoing other common procedures including bariatric surgery, hip and knee arthroplasty (THA and TKA, respectively). RESULTS A total of 90,551 elective spine surgery patients were identified in the NSQIP database, of which 3021 (3.3%) developed at least one HAC. SSI was the most common HAC (1.4%), followed by UTI (1.3%) and VTE (0.8%). Stratified by surgery type, fusion procedures were associated with higher rates of overall HACs compared to decompression-only procedures (1.0% vs. 0.5%, p CONCLUSIONS Spine surgery patients experienced an overall HAC rate of 3.3%, with surgical site infections occurring most frequently. When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review

Catheter-associated urinary tract infections (CAUTIs) are one of the most common hospital-acquired conditions and no longer reimbursable from Medicare as of 2008. Nurse-driven protocols (NDPs), which provide a medically approved rubric for professional nurses to make autonomous care decisions, can facilitate appropriate catheter use and timely removal, as advised in the Centers for Disease Control and Prevention's 2009 CAUTI prevention guidelines. However, little attempt has been made to systematically evaluate their effect on clinical outcomes. A systematic review of studies published in the United States since 2006 was performed, following guidelines from the Institute of Medicine. Sources included CINAHL, Medline, professional agencies, hand-searching, and expert consultation. Clinical predictors and prevalence of CAUTI were examined and synthesized qualitatively; heterogeneity of outcomes made a statistical meta-analysis inappropriate. Twenty-nine studies were found eligible for inclusion. All used a case-control (pre-post) approach, and all reported reductions in clinical predictors of CAUTI, particularly indwelling-urinary catheter utilization and CAUTI rates. However, the number of CAUTIs remained unchanged in 1 study. A formal quality assessment revealed a high risk of bias; included studies met an average of 4.9 out of 11 quality indicators. Specifically, many did not use standardized measures. NDPs appear to have a positive impact on the clinical predictors and prevalence of CAUTI. However, this review identified need for improving the study design of quality improvement projects conducted within the patient care setting.

Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms.

BackgroundInpatient falls and subsequent injuries are among the most common hospital-acquired conditions with few effective prevention methods.ObjectiveTo evaluate the effectiveness of patient education videos and fall prevention visual signalling icons when added to bed exit alarms in improving acutely hospitalised medical-surgical inpatient fall and injury rates.DesignPerformance improvement study with historic control.SettingFour medical-surgical units in one US public acute care hospital.Study participantsAdult medical-surgical inpatients units.InterventionsA 4 min video was shown to patients by trained volunteers. Icons of individual patient risk factors and interventions were placed at patients’ bedsides. Beds with integrated three-mode sensitivity exit alarms were activated for confused patients at risk of falling.Main outcome measuresThe main outcome measure is the incident rate per 1000 patient days (PDs) for patient falls, falls with any injury and falls with serious injury. The incident rate ratio (IRR) for each measure compared January 2009–September 2010 (baseline) with the follow-up period of January 2015–December 2015 (intervention).ResultsFalls decreased 20% from 4.78 to 3.80 per 1000 PDs (IRR 0.80, 95% CI 0.66 to 0.96); falls with any injury decreased 40% from 1.01 to 0.61 per 1000 PDs (IRR 0.60, 95% CI 0.38 to 0.94); and falls with serious injury 85% from 0.159 to 0.023 per 1000 PDs (IRR 0.15, 95% CI 0.01 to 0.85). Icons were not fully implemented.ConclusionThe first known significant reduction of falls, falls with injury and falls with serious injury among medical-surgical inpatients was achieved. Patient education and continued use of bed exit alarms were associated with large decreases in injury. Icons require further testing. Multicentre randomised controlled trials are needed to confirm the effectiveness of icons and video interventions and exit alarms.

Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm.

To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs). A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions. Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; P < .005 for all). The mean monthly SSE rate decreased 32% (from 0.77 to 0.52; P < .001). The 12-month rolling average SSE rate decreased 50% (from 0.82 to 0.41; P < .001). Participation in a structured collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm.

Effects of registered nurse staffing level on hospital-acquired conditions in cardiac surgery patients: A propensity score matching analysis

BackgroundThe ramifications of inadequate nurse staffing may have serious consequences due to reimbursement policies. PurposeTo determine the effects of registered nurse staffing on hospital-acquired conditions in cardiac surgery patients. MethodData from the 2009 to 2011 Nationwide Inpatient Sample were used to construct a propensity score-matched cohort. Multivariate regressions were performed to compare the probability, length of stay, mortality, and costs of three common hospital-acquired conditions between low- and high-staffing hospitals. ResultsA total of 439,365 patients in low-staffing hospitals were 1:1 matched to patients in high-staffing hospitals. High-staffing hospitals had 10% to 25% fewer cases (adjusted odds ratio [AOR] 0.75–0.90, p < .0001), 5% to 20% lower mortality (AOR 0.80–0.95, p < .0001), and 4% to 6% shorter length of stay (coefficient −0.06 to −0.04, p < .0001). The costs for patients with hospital-acquired conditions were 13% to 17% greater in high-staffing hospitals (coefficient 0.13–0.17, p < .0001). ConclusionsAlternatives to the current staffing and reimbursement policies should be considered to reduce hospital-acquired conditions.

Prevalence, Impact, and Risk Factors for Hospital-Acquired Conditions after Major Surgical Resection for Cancer: A NSQIP Analysis

BackgroundThe effectiveness of the CMS nonpayment policy for certain hospital-acquired conditions (HAC) is debated, since their preventability is questionable in several groups of patients. This study aimed to determine the rate of the three most common HAC in major surgical resections for cancer: surgical site infection (SSI), urinary tract infection (UTI), and venous thromboembolism (VTE). Additionally, the association of HAC with patients’ characteristics and their effect on post-operative outcomes were investigated. MethodsPatients who underwent surgical resection for esophageal, gastric, hepato-biliary, pancreatic, colorectal, and lung cancer were identified using the ACS-NSQIP database (2005–2012). Early surgical outcomes were compared between HAC and non-HAC patients. Modified Poisson regression was used to identify risk factors for developing HAC. ResultsSeventy-four thousand three hundred eighty-one patients were identified, of whom 9,479 (12.74 %) developed one or more HAC. HAC patients had significantly higher rates of 30-day mortality, return to operating room, 30-day readmission, had longer LOS, and were less likely to be discharged home. Several peri-operative patients’ factors were significantly associated with HAC. ConclusionOur data show that the development of HAC is strongly associated to pre-operative patients’ characteristics and not only to sub-optimal peri-operative care, therefore suggesting that the nonpayment policy might be excessively penalizing.

Establishing standard performance measures for adult brain tumor patients: a nationwide inpatient sample database study

The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services (CMS) hospital acquired conditions (HACs) are used to evaluate the safety and quality of health care. We determined the incidence rates of PSIs and HACs among brain tumor patients in the Nationwide Inpatient Sample database (NIS). We queried the NIS for all hospitalizations involving a brain tumor. We determined the incidence rates of various PSIs and HACs among these patients by searching the hospital records for codes in the International Classification of Diseases, 9th Revision indicating each PSI or HAC. Among the 501 908 hospitalizations involving a brain tumor in the NIS, there were 102 046 occurrences of an AHRQ PSI, with 16% of patients experiencing one or more AHRQ PSI. Among brain tumor patients treated without surgery, 17.2% experienced ≥ 1 PSI. Among brain tumor patients treated with surgery, 9.8% experienced ≥ 1 PSI. The most common PSIs were postoperative respiratory failure, deep vein thrombosis, and sepsis. The total number of HACs associated with brain tumor patients was 13 778, with 2.63% of patients experiencing ≥1 HAC. Among brain tumor patients treated without surgery, 3.0% experienced ≥ 1 HAC. Among brain tumor patients treated with surgery, 7.4% experienced ≥ 1 HAC. The most common HACs were falls and trauma and pressure ulcers. Increasing comorbidity score was associated with increased likelihood of almost all PSIs and HACs. These data may be used to determine individual institutional improvements or success by comparison.

Establishing Standard Performance Measures for Adult Stroke Patients: A Nationwide Inpatient Sample Database Study

The Agency for Healthcare Research and Quality patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are used to evaluate the safety and quality of health care provided by health care systems and individual facilities. To understand better the incidence of PSIs and HACs in hospitalized patients with stroke, we determined the rates of these events among patients with a diagnosis of stroke in the Nationwide Inpatient Sample (NIS) database. We queried the NIS for all hospitalizations involving ischemic stroke. We determined the incidence of various PSIs and HACs by searching the hospital records for International Classification of Diseases, 9th edition, codes indicating each PSI or HAC. Statistical analysis was performed with SAS statistical software package. There were 903,647 hospitalizations involving stroke in the NIS database for years 2002-2010. Among these hospitalizations, 137,161 (15.2%) patients experienced ≥1 Agency for Healthcare Research and Quality PSIs. The most common PSIs included postoperative respiratory failure (9.44%), sepsis (4.43%), and pressure ulcer (2.19%). Of stroke patients, 28,323 (3.13%) experienced ≥1 HACs. The most common HACs included falls and trauma (2.51%) and stage III and IV pressure ulcers (0.43%). Increasing comorbidity score (P ≤ 0.001) was associated with increased likelihood of all PSIs and HACs. The presence of PSIs or HACs resulted in increased length of stay, increased hospital charges, and an increase in mortality rates (P < 0.0001). Our results estimate baseline national incidence rates of PSIs and HACs in patients with stroke. These data may be used to determine individual institutional improvements or success by comparison.