The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.
Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.
“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”
He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.
About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.
“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.
The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.
Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.
“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”
Difficulties
For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).
A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.
For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).