5 Strategies for Preventing Avoidable Hospital-Acquired Conditions

Effective July 1, CMS will expand its non-payment policy for hospital-acquired conditions beyond Medicare to Medicaid patients, intensifying pressure on private hospitals to prevent HACs. Based on our six-year-old effort at the 469-bed Dallas VA Medical Center to prevent HACs in the intensive care unit setting, I recommend facilities deploy the following proven strategies to control infections:

1. Interface electronic health records to bedside monitors and medical devices. Many hospitals are implementing EHRs to quality for ARRA funds. Linking those systems to monitors, medical devices and other clinical information systems is the next crucial action to preventing avoidable infections. This connectivity helps clinicians recognize and take appropriate steps to reduce HACs by centralizing data in one place. By interfacing our CliniComp Essentris® Critical Care® System with monitoring devices, Dallas VAMC was able to decrease central venous catheter–related bloodstream (CRBSI) infections in 2006 at its medical ICUs from 9.9 to 1.0 per 1,000 patient days, and from 5.8 to 0.8 per 1,000 patient days in the surgical ICU today. Follow-up and continued surveillance has maintained low levels of central line and ventilator associated pneumonia infections to the current date.

2. Adhere to evidence-based medicine. CRBSI infections, ventilator-associated pneumonia, surgical site infections and catheter-associated urinary tract infections comprise four types of infections that account for more than 80 percent of hospital-acquired conditions in the U.S., according to the Agency for Healthcare Research and Quality. Many of those infections can be prevented through adherence to evidence-based clinical best practices.

3. Create computerized checklists. It is easy for physicians and nurses to unintentionally forget to follow best practices when they are in crisis mode treating multiple patients in the ICU, emergency department (ED) and other high acuity care areas. Facilities can avoid this circumstance by building and integrating computerized checklists into their daily workflow for clinicians to access at the point of care. For example, hospitals can reduce VAP infections by elevating the head of the bed of patients on mechanical ventilation by more than 30 degrees and assessing those patients daily to determine whether to decrease sedative administration and wean individuals off ventilators as quickly as possible.

4. Transfer patients out of the ICU and ED as soon as appropriate. The longer that critically ill patients remain in the ICU and ED, the higher the risk of their chances contracting an infection. As a result, an infected patient will drive up additional costs and length of stay and the risk of mortality. To date, Dallas VAMC has focused on preventing ICU infections first because ICU patients are most vulnerable to developing and dying from infections. Improvement in this setting is the solution to significantly enhancing care and reducing health spending. According to a study published last year in Critical Care Medicine, ICU-acquired infections account for 13.4 percent of hospital costs, 4.1 percent of national health expenditures, and 0.66 percent of the gross domestic product.

5. Standardizing clinical language. Currently, Dallas VAMC is standardizing clinical terms among its disparate ICU, inpatient, operating room, anesthesia and inpatient clinical information systems to support better reporting and data mining. Our goal is to identify best practices and improve outcomes.

William "Claibe" Yarbrough, MD, is an intensivist and chief of intensive care unit informatics at the Dallas VA Medical Center.

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