Under Medicare's Hospital-Associated Conditions (HAC) Reduction Program, America's hospitals face a large financial risk that warrants the close attention of chief financial officers. In fiscal year (FY) 2015--the program's first year--721 U.S. hospitals incurred estimated penalties totaling $373 million1 for having the highest rates of central lines-associated bloodstream infections (CLABSIs) and other patient injuries.
The program docks the 25 percent of hospitals with the worst rates of certain complications, such as the accidental puncture and collapse of the patient's lung during central-line placement (iatrogenic pneumothorax), one percent of their annual Medicare payments.
On January 1, 2015, CMS expanded reporting of CLABSIs beyond the intensive care unit to all medical surgical beds through the hospital, with the data to be used as one of the measures to determine which hospitals are penalized under the HAC program, starting in October, 2017.2
In this environment, it is essential for financial leaders to understand how the penalty program works and which safety practices offer the best protection against costly medical errors. Here is an overview of how ultrasound guidance can reduce--or even eliminate-- central line-complications, including those targeted by the HAC program, based on robust medical evidence and my experience as an emergency physician at a large medical center.
Ultrasound Guidance Helps Prevent $6 Million Mistakes
CLABSIs and pneumothorax are two of the most expensive and dangerous adverse events associated with central line placement. Also known as central venous catheterization (CVC), this procedure is performed more than five million times a year in U.S. hospitals3 with reported complication rates exceeding 15 percent4 if the needle is inserted "blindly" (using anatomical landmarks to estimate the location of the target blood vessel).
About 250,000 CLABSIs occur annually in the U.S., with an estimated attributable mortality of up to 25 percent and an estimated cost of up to $56,000 per infection, reports the Centers for Disease Control (CDC).5 6Pneumothorax lengthens hospital stay by 4 to 7 days at an additional cost of up to $45,000 per case.7 Not only does Medicare no longer reimburse these costs, but they can escalate if injured patients sue: An analysis of closed malpractice claims reported payments as high as $6.9 million for CVC complications8.
Evidence-based guidelines from many medical organizations, including the Centers for Disease Control (CDC)9, American College of Emergency Physicians10, and the National Institute of Clinical Excellence (NICE),11 recommend ultrasound-guided central line placement based on its overwhelming safety benefits.
At many leading hospitals, including the one where I practice, ultrasound-guided CVCs are now the standard practice--not just to improve safety, but also to obtain faster vascular access during emergencies, when every second counts. Many studies show that this technique is more likely to succeed on the first try, accelerating potentially life-saving treatment of critically injured or ill patients.
Best Practices to Improve Central-Line Infection Control
My hospital, like many others, uses a bundle of CVC safety practices to lower risk for CLABSIs. Drawing on robust scientific research, our bundle is comprised of these six components.
• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Daily review of CVC line necessity, with prompt removal of unneeded lines
• Optimal catheter site selection
• Ultrasound-guided line placement
To minimize infection risk, the CDC recommends the subclavian vein in the upper chest as the safest site for CVC in adult patients. In a 2015 multicenter randomized study12 of 3,027 patients bears this out, with the researchers reporting that rates of CLABSI and blood clots were 3.5 times higher if CVC was performed on the femoral vein, and 2.1 times higher if the jugular vein was the CVC site, compared to the subclavian vein.
Not only is the subclavian vein the optimal site for CVC, but risk for complications is further reduced--or even eliminated--with ultrasound guidance. A recent randomized, controlled study13 of critical care patients who received subclavian CVC reported zero percent rates of pneumothorax and hemothorax, compared to rates of 4.9 percent and 4.4 percent respectively with landmark techniques. All other HACs were also reduced or eliminated with ultrasound guidance.
The CDC's guidelines for CVC infection prevention offer this advice to clinicians: "Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications."
Using Ultrasound-Guided Peripheral IVs to Avoid Unnecessary CVCs
Increasingly, in our emergency department, patients are asking for ultrasound-guided peripheral IV (PIV). Often, they will say, "I'm a 'difficult stick' and the last time I got an IV, the doctor used ultrasound." That's because patients with difficult vascular access due to obesity, chemotherapy, IV drug abuse or other factors, have discovered that that if their PIV is inserted with ultrasound guidance, they don't have to be repeatedly jabbed with a needle.
It's easy to see why these patients are concerned. Studies have reported failure rates for emergent PIV access of up to 40 percent. And even with PIV access is ultimately achieved in patients with problematic vascular access, it can take up 30 minutes,14 leading to potentially dangerous delays in treatment for the very people who need it most.
A recent study highlights the benefits of ultrasound-guided PIV for patients with problematic vascular access.15 The researchers found that ultrasound-guided PIV prevented the need for a central line in 85 percent of cases, sparing those patients such dangerous CVC-associated risks as pneumothorax and CLABSI. The patients were tracked for seven days and had zero complications.
Even newer research suggests that ultrasound-guided PIV may be an option in some scenarios when a central line used to be deemed essential. For example, a September, 2015 study of 734 intensive care unit patients found that PIV access can often be safety used to administer vasoactive medication, an important treatment to help prevent secondary complications in patients with life-threatening conditions like sepsis.
Amid mounting evidence of the many benefits of ultrasound-guided vascular access for improving the safety and the quality of hospital care, it's no wonder that patients are now demanding it. As we strive to improve America's healthcare, while also reining in costs, don't we owe to patients to adopt the proven best practices that lead to optimal outcomes?
Author bio: Haney Mallemat, MD is board certified in emergency medicine, internal medicine, and critical care medicine and works in the Emergency Department and Intensive Care Unit in Baltimore, Maryland. He has lectured both nationally and internationally, and has contributed to several emergency medicine and critical care podcasts. A firm believer in the benefits of bedside ultrasound for better patient care, Dr. Mallemat uses ultrasound to help educate medical students, residents, fellows, nurses, and mid-level providers. He was awarded the Department of Emergency Medicine "Outstanding Teaching Award" in 2012, 2013, and 2015.
1 Kaiser Health News Web site: "Medicare Cuts Payments To 721 Hospitals With Highest Rates Of Infections, Injuries." http://khn.org/news/medicare-cuts-payments-to-721-hospitals-with-highest-rates-of-infections-injuries/. Accessed October 27, 2015.
2 Federal Register, Vol. 80, No. 156, August 17, 2015.
3 Feller-Klopman, D, "Ultrasound-Guided Internal Jugular Access," Chest, July, 2007: http://journal.publications.chestnet.org/article.aspx?articleid=1085229
4 Merrer J, De Jonghe B, Golliot F et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286(6):700-7.
5 O'Grady NP, Alexander M et al. Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis, 2011 May 1; 52(9): 1087–1099.
6 O'Grady NP, Alexander M, Dellinger EP et al. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol. 2002 Dec;23(12):759-69.
7 Zhan C, M Smith and D Stryer. Incidences, Outcomes and Factors Associated with Iatrogenic Pneumothorax in Hospitalized Patients [abstract]. AcademyHealth Annual Research Meeting.; 2004; San Diego, Calif. Academy Health. 2004; 21: abstract no. 1862.
8 Domino, KB et al. Injuries and liability related to central vascular catheters-a closed claims analysis. Anesthesiology, 2004; 100(6), 1411-1418
9 O'Grady NP, Alexander M et al. Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis, 2011 May 1; 52(9): 1087–1099.
10 American College of Emergency Physicians Web site: "Policy Statement: Emergency Ultrasound Guidelines." http://www.acep.org/workarea/DownloadAsset.aspx?id=32878 Accessed October 27, 2015.
11 National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology Appraisal Guidance No. 49, September 2002.
12 Parienti JJ, Mongardon N et al. Intravascular Complications of Central Venous Catheterization by Insertion Site N Engl J Med 2015; 373:1220-1229.
13 Bodenham AR. Ultrasound-guided subclavian vein catheterization: Beyond just the jugular vein. Critical Care Medicine 2011;39:1819-1620.
14 Leidel BA, Kirchhoff C, Bogner V, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery. 2009; 3:24.
15 Au AK, Rotte MJ, Grzybowski RJ et al. Decrease in central venous catheter placements due to use of ultrasound guidance for peripheral intravenous catheters. American Journal of Emergency Medicine. November 2012; 30(9): 1950-4.
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