“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”
Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.
“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”
Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.
His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.
The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.
Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”
Early Reaction
While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.
“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”
And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.
The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.
Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.
“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH