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Hospital Acquired Conditions (HACs) “Stop HACs, Keep Patients Safe” James Pippim, MD, MPH, FACP, FCCP. Disclosures. None. Objectives. Describe the burden of HACs Identify the risk factors for HACs Discuss evidence based guidelines used to prevent HACs. Hospitals in the US.

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  1. Hospital Acquired Conditions (HACs)“Stop HACs, Keep Patients Safe”James Pippim, MD, MPH, FACP, FCCP

  2. Disclosures None

  3. Objectives • Describe the burden of HACs • Identify the risk factors for HACs • Discuss evidence based guidelines used to prevent HACs

  4. Hospitals in the US • American Hospital Association (2014) • 5700 Hospitals 921K Beds 36M Admissions $ 829B Total Expenses • Safest place to be for sick people • Around the clock access to skilled care teams • Continuous monitoring of pts vital signs • Checked on frequently by HC team

  5. Sobering Reality • 3X as many people die due to medical errors in our hospitals as die on our highways • It would take 200 747 airplane crashes annually to equal the 100K hosp. preventable deaths • Statements made about our hospitals • Best way to deal with them is to avoid them at all costs • Become a controlled beast as soon as you enter the ring because no one can protect you except you

  6. Why Are Hospitals So Unsafe? • Hospitals starve, sleep deprive and spread infections among patients • Med side effects, bed sores, broken bones, blood clots and loss of body parts • Medical errors are the 3rd leading cause of death in the US after heart dx and cancer

  7. “Stop The Hacks” A colloquial and usually pejorative term used to refer to writers who are paid to write low quality rushed articles or books with short deadlines. (“Mercenaries” or “Pens for Hire”) They were paid by the number of words in their articles or books so hacks had a reputation for quantity taking precedence over quality

  8. “Stop HACs” Current term used to describe providers who are paid to perform low quality services often with short deadlines. (“Hired Assassins” or “Stethoscopes for Hire”) Paid by the number of procedures performed so HACs have a reputation for quantitytaking precedence over quality

  9. What Are HACs? • Medical conditions or complications • Develops during a hospital stay • Was not present on admission • Preventable in most cases 80% of HACs are due to 1. CAUTI, CLABSI, VTE, VAP 2. Falls and Trauma, Pressure Ulcers 3. Obstetric Adverse Events, Surgical Site Infxns 4. Adverse Drug Events, 30-d Readmission Rates

  10. Very Important HACs 1. High cost or high volume conditions or both 2. That resulted in an MS-DRG with a higher payment when present as a 2ry diagnosis 3. That could reasonably have been prevented through the application of EBM guidelines 4. Would no longer receive higher payment if the condition was hospital acquired DRA Section 5001(c) US DHHS 10/2008

  11. 1. Vascular Catheter-Associated Infection (CLABSI) 2. Manifestations of Poor Glycemic Control 3. Surgical Site Infection (SSI) HAC Payment Provisions 4. Blood Incompatibility 5. Pressure Ulcer Stages III and IV 6. Falls and Trauma: 7. Catheter-Associated Urinary Tract Infection (CAUTI) 8. Foreign Object Retained After Surgery 9. Air Embolism 10. DVT and PE (TKR, HR) 11. Iatrogenic Pneumothorax with Venous Catheterization FYs 2014 and 2015 Categories

  12. Three Never Events • Wrong Patient • Wrong Body Part • Wrong Procedure

  13. How bad is the problem? • Total no. of HACs 4.1 Million (2012) • 1 in 9 hospital admissions • 132 HACs per 1000 discharges • 560K fewer HACs, 15K fewer deaths and $4 Billion saved c/t 2010 • Top 5 HACs • ADE (34%), HAPU (28%), Others (19%) • CAUTI (8%) and Falls (6%)

  14. Biofilm

  15. US Acute Care HAIs-2011 722K HAIs occurred in US acute care hospitals in 2011 75K of these hosp. pts died annually from their HAIs $30B in excess cost every year N Engl J Med March 27 2014; 370:1198-1208.

  16. Risk Factors for HACs

  17. CLABSIs

  18. Risk Factors for CLABSIs

  19. CAUTIs

  20. Risk Factors for CAUTI

  21. Risk Factors for HAPU

  22. Risk Factors for Falls 1. Lower body weakness 2. Difficulties with gait and balance 3. Use of psychoactive medications 4. Postural dizziness 5. Poor vision 6. Problems with feet and/or shoes 7. Hospital hazards

  23. 1. Before touching a patient 2. Before clean/aseptic procedures 3. After body fluid exposure/risk 4. After touching a patient 5. After touching patient’s surroundings

  24. HAI Reduction • Good Hand Hygiene by ALL providers • Checklists to ensure consistent care • Bundle up your approach to care • Team up and communicate • Be a role model/innovator

  25. CAUTI Prevention

  26. CAUTI Prevention

  27. CAUTI Prevention

  28. CAUTI Prevention • Insert catheters only for appropriate indications • Leave catheters in place only as long as needed • Ensure that only properly trained persons insert and maintain catheters • Insert catheters using aseptic technique and sterile equipment (acute care setting) • Following aseptic insertion, maintain a closed drainage system • Maintain unobstructed urine flow • Hand hygiene and Standard (or appropriate isolation) Precautions

  29. CLABSI Prevention • At insertion • Checklist to ensure adherence to infxn prevention practices • Hand hygienebefore catheter insertion or manipulation • 3. Avoid the femoral vein • 4. Use an all-inclusive catheter cart or kit. • 5. Use maximal sterile barrier precautions during insertion • 6. Use a chlorhexidine-based antiseptic for skin preparation After insertion1. Disinfect catheter hubs, needleless connectors & injection ports before accessing the catheter 2. Remove nonessential catheters 3. CHG baths/dressing and antimicrobial catheters

  30. SSI: Effective interventions 1. Administer antimicrobial prophylaxis 2. Do not remove hair at the operative site unless the presence of hair will interfere with the operation 3. Do not use razors 4. Control blood glucose level during the immediate post op period for pts undergoing cardiac surgery 5. Measure and providefeedback to providers on their compliance rates with the above process measures

  31. VAP: Effective interventions • Implement policies and practices for disinfection, • sterilization & maintenanceof resp. equipment • 2. Provide easy access to noninvasive ventilation • equipment & use weaning protocols. • 3. Ensure that pts are maintained in a semi-recumbent • position • 4. Perform antiseptic oral care according to product • guidelines

  32. 2010 - That Was Then

  33. 2014 - This Is Now 1) Foreign Object Retained After Surgery 2) Air Embolism 3) Blood Incompatibility 4) Stage III and IV Pressure Ulcers 5) Falls and Trauma Fractures, Dislocations, Intracranial Injuries, Burns Crush Injuries, Electric Shock

  34. 2014 HACs-This Is Now 6) Manifestations of Poor Glycemic Control DKA, NKHC, Hypoglycemia, 2ry DM + KA, 2ry DM + Osm. 7) Catheter-Associated Urinary Tract Infection (UTI) 8) Vascular Catheter-Associated Infection 9) Surgical Site Infection CABG, CEID, Bariatric Surgery, Orthopedic Procedures 10) DVT/PE TKR, Hip Replacement

  35. Domain 1 AHRQ* PSI 90 Measure Score 1-10 PSI 3 Pressure ulcer rate PSI 6 Iatrogenic pneumothorax rate PSI 7 CVC related blood stream infection rate PSI 8 Postoperative hip fracture rate PSI 12 Postoperative PE or DVT PSI 13 Postoperative sepsis rate PSI 14 Wound dehiscence rate PSI 15 Accidental puncture and laceration rate

  36. Domain 2 CDC NHSN Measures Average Score 1-10 CLABSI SIR rate 1-10 CAUTI SIR rate 1-10 Performance Period (7/1/2011– 6/30/2013) Future Measures For FY2016 SSI Colon SSI Abdominal Hysterectomy Future Measures For FY2017 MRSA CDI

  37. Summary • Common, costly and frequently fatal • 10 conditions account for 80% of HACs • Extrinsic risks factors maybe modifiable • Evidence based preventive guidelines may help decrease its incidence and impact • Adhere to EBM, Bundles of care, Checklists and Discharge pts from high risk areas

  38. I LOVE sick people but I don’t like signing Death Certificate

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