Write two Abstracts

PRACTICE APPLICATIONS Business of Dietetics

Hospital-Acquired Conditions: Knowing, Preventing, and Treating Them Can Make RDs and DTRs an

Invaluable Part of the Health Care Team

T HEY’RE A PATIENT’S WORST nightmare and the recipe for a lawsuit. Each year, the Centers for Disease Control and Pre-

vention estimates that hospital-acquired conditions (HACs) number in the millions and result in billions of dollars lost in reim- bursementstohealthcareproviders.These incidents can significantly damage one’s credibility and potentially spark litiga- tion. Registered dietitians (RDs) can play a lead role within the teams they work because a number of HACs are related to nutrition. Awareness of these conditions and how nutrition can factor into their cause, as well as treatment, can also make the RD an invaluable player in a number of environments. As quality con- trol becomes an increasingly important measure in determining reimbursement, theskillspossessedbyanRDcanincrease their value to health care teams. Cor- rectly identifying these issues before theyadvanceinacuitycansaveproviders a substantial amount of money and im- prove overall quality scores. Ultimately, education is the primary tool to prevent and treat events that, by definition, should never happen.

SIMILAR PROBLEM, DIFFERENT TERMS In broaching the topic, the terms Hospi- tal-Acquired Conditions and Never Events might seem interchangeable depending on the speaker, but in point of fact they represent entirely different sets of condi- tions. The term Never Events refers to the list of serious reportable events first en- dorsed by the National Quality Forum (NQF) in 2002 (1), a compilation of 28 oc- currences classified under any of six cat- egories:

This article was written by Brian Boyce, an award-winning freelance writer in Terra Haute, IN.

doi: 10.1016/j.jand.2012.02.016

476 JOURNAL OF THE ACADEMY OF NUTRITI

• surgical; • product or device; • patient protection; • care management; • environment; and • criminal. The term Never Events was first in-

troduced in 2001 at the NQF by Ken Kizer, MD, MPH, current director of the Health Improvement Center at the University of California at Davis, in re- sponse to what was determined to be a large number of preventable inci- dents. Meanwhile, the term Hospital-Ac-

quired Conditions refers to regulations set in place with the passage of the Deficit Reduction Act of 2005, which required a quality adjustment in Medicare Severity Diagnosis-Related Group payments for certain hospital- acquired conditions. The Centers for Medicare and Medicaid Services (CMS) titled the provision “Hospital- Acquired Conditions and Present on Admission Indicator Reporting” (2). According to Section 5001c of the Def- icit Reduction Act, HACs were initially defined by their meeting of at least two conditions that:

• are high cost, high volume, or both;

• result in the assignment of a case to an Medicare Severity Diagno- sis-Related Group that has a higher payment when present as a secondary diagnosis; and

• could reasonably have been pre- vented through the application of evidence-based guidelines.

The statute also allows the CMS to re- vise its list of conditions, granted they meet those guidelines (2). As Nancy Collins, PhD, RD, LD/N,

FAPWCA, observed, the lists have some

ON AND DIETETICS © 2

cross-over, although knowing the dif- ference can determine whether one is reimbursed or declined payment. In- creasing one’s awareness of the overall concept is the best way to avoid the oc- currences in any case. Collins is founder and executive direc-

tor of RD411.com, Inc, as well as the co- author of a session titled “CMS Never Events and Litigation: A Roadmap to Stopping Never Events,” delivered at the Academy of Nutrition and Dietetics’ 2011 Food & Nutrition Conference & Expo (3) along with Courtney H. Lyder, ND, RD, FAAN, dean and professor of the school of nursing at the University of California, Los Angeles. The session pro- vided information about these events and ways to prevent litigation. A na- tionally recognized expert on wound care and medical litigation, Collins said that depending on which source one uses, the number of preventable inci- dents could range up to 42 and they can change over time. Not enough RDs are aware of these incidents as they pertain to reimbursement though, and further education is crucial.

HACs DEFINED The October 2010 CMS list of events no longer reimbursed (2) includes:

• foreign object retained after sur- gery;

• air embolism; • blood incompatibility; • stage III and IV pressure ulcers; • falls and trauma (fracture, dislo-

cation, intracranial injury, crush- ing injury, burn, electric shock);

• catheter-associated urinary tract infection;

• vascular catheter-associated in- fection;

• manifestations of poor glycemic

control (diabetic ketoacidosis,

012 by the Academy of Nutrition and Dietetics.

PRACTICE APPLICATIONS

nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, sec- ondary diabetes with hyperos- molarity);

• surgical site infection, mediasti- nitis, following coronary artery bypass graft;

• surgical site infection following certain orthopedic procedures (spine, neck, shoulder, elbow);

• surgical site infection following bariatric surgery for obestity (laparoscopic gastric bypass, gastroenterostomy, laparo- scopic gastric restrictive sur- gery); and

• deep vein thrombosis and pul- monary embolism following or- thopedic procedures (total knee replacement, hip replacement).

The CMS states that: “For discharges occurring on or after Oct. 1, 2008, hos- pitals will not receive additional pay- ment for cases in which one of the se- lected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present” (2). The NQF list of serious reportable

events includes:

• Surgery performed on the wrong body part.

• Surgery performed on the wrong patient.

• Wrong surgical procedure per- formed on patient.

• Unintended retention of a for- eign object in a patient.

• Artificial insemination with the wrong sperm or donor egg.

• Intraoperative or immediately postoperative death in an Amer- ican Society of Anesthesiologist class I patient.

• Patient death or disability associ- ated with use of contaminated drugs, devices, or biologics pro- vided by the health care facility.

• Patient death or serious disabil- ity associated with the use or function of a device in patient care, in which the device is used for functions other than as in-

tended.

478 JOURNAL OF THE ACADEMY OF NUTRITI

• Patient death or disability associ- ated with intravascular air em- bolism that occurs while being cared for in a health care facility.

• Infant discharged to the wrong person.

• Patient death or serious disabil- ity associated with patient elope- ment (disappearance).

• Patient suicide or attempted sui- cide resulting in serious disabil- ity, while being care for in a health care facility.

• Patient death or serious disabil- ity associated with a medication error.

• Patient death or serious disabil- ity associated with a hemolytic reaction due to the administra- tion of ABO/human leukocyte an- tigen (HLA)-incompatible blood or blood products.

• Maternal death or serious dis- ability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility.

• Patient death or serious disabil- ity associated with hypoglyce- mia, the onset of which occurs while the patient is being cared for in a health care facility.

• Death or serious disability (ker- nicterus) associated with failure to identify and treat hyperbiliru- binemia in neonates.

• Stage III or IV ulcers acquired af- ter admission to a health care fa- cility.

• Patient death or serious disabil- ity due to spinal manipulative therapy.

• Patient death or serious disabil- ity associated with an electric shock or electrical cardioversion while cared for in a health care facility.

• Any incident in which a line des- ignated for oxygen or other gas to be delivered to a patient contains the wrong substances, or is con- taminated by toxic substances.

• Patient death or serious disabil- ity associated with a burn in-

curred from any source while be-

ON AND DIETETICS

ing care for in a health care facility.

• Patient death or serious disabil- ity associated with a fall while being cared for in a health care facility.

• Patient death or serious disabil- ity associated with the use of re- straints or bedrails while being care for in a health care facility.

• Any instance of care ordered or provided by someone imperson- ating a physician, nurse or phar- macist, or other licensed health care provider.

• Abduction of a patient of any age. • Sexual assault on a patient

within or on the grounds of the health care facility.

• Death or significant injury of a patient or staff member resulting from a physical assault that oc- curs within or on the grounds of the health care facility.

NUTRITION LEADERS AS HEALTH CARE LEADERS Collins, speaking from her office, ex- plains that nutrition plays a significant role in the treatment and prevention of multiple HACs and Never Events. In particular, these include stage III and IV pressure ulcers, manifestations of poor glycemic control, surgical site infec- tions, and falls. RDs in the field understand the role

nutrition plays in these particular is- sues and support is well documented. In her own presentation on the topic, Collins references one 15-study meta- analysis finding that enteral nutritional support, particularly high protein oral nutritional supplements, can reduce the risk of developing pressure ulcers (4), and she notes that poor nutrition is a contributing cause of pressure ulcers in 61% of cases. Collins said that nutrition also factors

in the prevention of falls, explaining that patients can lose lean body mass while hospitalized, weakening their muscles, and increasing fatigue. Poor nutrition hinders the body’s recovery process, and she observed that it’s tough to do physical therapy without the en- ergy provided by proper nutrition. “If you don’t eat for three days it’s

hard to do your physical therapy,” she

remarked.

April 2012 Volume 112 Number 4

PRACTICE APPLICATIONS

Regarding infection control, every wound care team should have an RD be- causeoftherelationshipbetweenwound care and nutrition; but for RDs to play theirrole,continuingeducationisamust. RDs might already know their roles

and the impact nutrition plays in recov- ery and treatment, but communicating this relevance as it relates to HACs and potential reimbursement cuts is essen- tial, Collins said. Other health care providers have also

recognized this need, and in March the Philadelphia, PA–based health care in- formation services provider Elsevier launched an online tool to help nurses prevent the HACs identified by the CMS. The database is available on Elsevier’s Mosby’s Nursing Consult Web site (www.nursingconsult.com) in the section titled “Never Events.” Each HAC is matched with appropri-

ate articles, reports, monographs, and studies. Nurses who access the sections are able to review the medical defini- tion of each HAC, evidence-based nurs- ing content, books, imaging, and news updates. The online tool also includes decision-making guidance on six con- ditions currently under review by CMS for inclusion into the HAC list: delirium, ventilator-associated pneumonia, Staphylococcus aureus septicemia, Clos- tridium difficile-associated disease, Le- gionnaire’s disease, and iatrogenic pneumothorax. This Web site is avail- able to RDs as subscribers, but other re- sources are also online. Collins founded and operates www.

RD411.com, which features an online database of articles and relevant re- search in the field of health care and nutrition. Her course on the topic and its relationship to malpractice lawsuits is available through Abbott Nutrition Health Institute, and can be used by RDs for continuing education credit. Collins expressed the need for more continu- ing education on this topic. She says the difficult part is that nobody seems to be talking about this. On the other hand, the potential of

HACs to spark litigation is a concern shared by all in health care, and Collins said explaining the financial and career impact that these events can have is a big motivator.

MISTAKES ARE COSTLY The Centers for Disease Control and

Prevention estimates approximately

April 2012 Volume 112 Number 4

1.7 million hospital-associated infec- tions occur each year in US hospitals (5). Of these, an estimated 98,987 re- sulted in deaths. Overall, hospital-asso- ciated infections alone are believed to add $20 billion a year to the nation’s health costs (6). As Collins explained in her presenta-

tion at the Academy’s Food & Nutrition Conference & Expo, the initial goal of the NQF was to identify errors and de- velop a system that improved patient safety. The project began as part of a federally funded, five-state pilot proj- ect to organize the reporting of adverse events. The list, she states, was never originally intended to become a pay- ment tool. Over the years, however, the process has culminated in these inci- dents being labeled unacceptable for payment, and in some cases hospitals will simply not charge the patient be- cause a denied charge could be used in a malpractice suit, she said. This shift has made the proper iden-

tification, documentation, and coding of conditions extremely important so as to note them as present on admis- sion, if applicable. But the raw numbers of lost reim-

bursement is substantial. Citing CMS data (3), Collins noted that in 2007, 257,412 cases of stage III and IV pres- sure ulcers were reported at a cost-per- stay of $43,180. Some 193,566 cases of “falls and trauma” were reported that year at $31,894 each. Deep vein throm- bosis/pulmonary embolism tabbed 140,010 cases at $50,937 each. And vas- cular catheter-associated infections were reported at a volume of 29,536, costing $103,627 each. With the gross total of billings affected by pressure ul- cers alone coming in at more than $1.1 billion, the overall impact on revenue is significant. And it’s a trend that she ob- served is already being followed by companies such as Wellpoint (India- napolis, IN), the nation’s largest com- mercial insurer. The move toward reimbursing based

on quality is already underway, Collins said, predicting that hospitals graded in the top 20% of quality standards will soon be incentivized monetarily. Hos- pitals in the bottom 20% will be penal- ized. Health care specialists who focus on post-discharge treatment are be- coming increasingly important as hos- pital emergency departments don’t

want patients readmitted for fear of

JOURNAL OF THE ACADE

negative ratings. The roles RDs can play in these arenas are substantial if they understand the language, know what to look for, and know how to manage the process. “So there are going to be a lot of op-

portunities for dietitians in home care,” she said, explaining that regardless of the quality of an emergency depart- ment physician’s care and instruction, a patient’s failure to follow proscribed nutritional guidelines can negatively affect their outcome. The term dis- charge is becoming obsolete given that reimbursements will be determined, in part, on readmission rates, and those rates are impacted by what occurs after the patient leaves the facility. Thus, hospitals are looking to partner with home-care agencies, and those agen- cies will be graded on their ability to lower readmission rates, she said. Agencies with RDs on the staff will have more success than those that do not, she added, noting the number of pa- tients who lose lean body mass while in the hospital and require nutritional consideration once home.

MY OF NUTRITION AND DIETETICS 479

PRACTICE APPLICATIONS

This creates just one of many oppor- tunities for RDs who are aware of the issues. From educating other health care workers on the importance of rec- ognizing HACs, to prevention and treat- ment, clinical facilities have a vested in- terest in using nutrition as a tool. Given the role nutrition plays in issues such as falls, the potential for RDs to be placed on quality control panels within an in- stitution is present. Also, just as diabe- tes education opened the door for many RDs to gain prominence within facili- ties, the role nutrition plays in pressure ulcers can do the same. RDs should con- sider their value in offering consulta- tion services to other health care pro- viders, including orthopedic surgeons who perform hip and other joint re- placements as these procedures often place patients in bed for extended peri- ods of time. The key to accessing these opportunities will require education and collaboration, both of which pres- ent opportunities in and of themselves. Nationally, there is concern about

whether progress is truly being made. A statewide study of 10 North Carolina hospitals tracked harm resulting from medical care over a 6-year period ending in December of 2007 (7). Researchers de- termined that patient harm was com- monandthequantityofincidentsdidnot decrease over time. In 2,341 adult ad- missions reviewed, there were 25 epi- sodes of harm per 100 admissions, with 18% unique patient admissions that had incidents determined to be of harm. That rate was deemed unacceptable given the amount of awareness one would expect in a health care facility. Although disappointing, the absence

of apparent improvement is not en- tirely surprising. Despite substantial al- location and efforts to draw attention to the patient safety epidemic on the part of government agencies, health care regulators, and private organiza- tions, the penetration of evidence-

based safety practices has been quite

April 2012 Volume 112 Number 4

modest. For example, only 1.5% of hos- pitals in the United States have imple- mented a comprehensive system of electronic medical records, and only 9.1% have even basic electronic record keeping in place; only 17% have com- puterized provider order entry. Physi- cians-in-training and nurses alike rou- tinely work hours in excess of those proven to be safe. Compliance with even simple interventions such as hand washing is poor in many centers (7). Meanwhile, Collins noted that in

2003, Minnesota became the first state to pass laws requiring the mandatory reporting of 27 NQF measures to the state hospital association. By 2006, this resulted in the reporting of 154 adverse events out of more than 8 million visits. This total included 48 pressure ulcers, 42 retained objects, 23 wrong-site sur- gery, and 12 falls. By 2008, the state re- port showed a decrease of events from the year prior; however, a total of 125 events were still recorded from 38 hos- pitals and four surgery centers. These included 13 deaths and 10 serious dis- abilities. The most common issue was once again pressure ulcers.

THREATS AND OPPORTUNITY An entire team of health care profes- sionals can be at risk if one member fails to fulfill their role. Consider the impact nutrition plays in a patient’s physical energy levels. In the hypothet- ical example where a patient, weak- ened by lack of nutrition, does not per- form their requisite physical therapy, the entire network of health care pro- fessionals could be at risk. Trauma re- lated to falls is just one of the HACs that could ensue in any number of patients undergoing different procedures rang- ing from hip replacements to spinal in- jury. The ability RDs possess to treat pressure ulcers is just another example of their value to the overall team, which in the end gets judged together. The im-

portance that nutrition plays in the

JOURNAL OF THE ACADE

overall scope of wellness is something RDs can actively promote throughout the course of their work. Understand- ing that reimbursement potentially hangs in the balance makes for just one additional argument RDs have on their side as they take leadership roles within the field. And as the cost of health care continues to dominate na- tional headlines, the amount of losses written off by hospitals and providers will likewise continue, right along with patients’ concerns for well-being.

References 1. National Quality Forum. Serious Report-

able Events. http://www.qualityforum.org/ Publications/2008/10/Serious_Reportable_ Events.aspx. Accessed October 11, 2011.

2. Centers for Medicaid and Medicare Ser- vices. “Hospital-Acquired Conditions and Present on Admission Indicator Report- ing.” Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals. https://www. cms.gov/HospitalAcqCond/Downloads/ HACFactsheet.pdf. Accessed December 21, 2011.

3. Collins N, Lyder CH. CMS Never Events and litigation: A roadmap to stopping never events. Abbott Nutrition Health Instit- ute Web site. http://anhi.org/learning/ coursedetail.aspx?ID�D9F6EF9391FF4B58 BA74C8D72F166F5F. Accessed December 21, 2011.

4. Stratton RJ, Ek A-C, Engfer M, et al. Enteral nutritional support in prevention and treat- ment of pressure ulcers: A systematic re- view and meta-analysis. Ageing Res Rev. 2005;4:422-450.

5. Monina KR, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infec- tions and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1820440/pdf/phr122000160.pdf. Acce- ssed December 21, 2011.

6. Anand P; Health Care Infection Control Practices Advisory Committee. HHS ef- forts to reduce health care-associated in- fections. http://www.cdc.gov/hicpac/pdf/ HHSpresentationHICPAC_11_08.pdf. Acce- ssed December 21, 2011.

7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting

from medical care. N Engl J Med. 2010;363: 2124-2134.

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