Hospitals now have a powerful new incentive to reduce central line-associated bloodstream infections (CLABSIs): On Jan. 1, 2015, CMS expanded reporting of these infections beyond the intensive care unit to all medical and surgical beds throughout the hospital. In August, Medicare announced plans to use this data as one of the measures to determine which hospitals will be penalized under its new Hospital-Acquired Condition (HAC), starting on Oct. 1, 2017. Expanded reporting is likely to have significant financial impact, considering that poorly performing hospitals incurred an estimated $330 million in penalties in FY 2015, the HAC program’s first year. CMS calculates each hospital’s HAC score, based on its rate of CLABSIs and other preventable complications, such as the accidental puncture and collapse of the patient’s lung during central line insertions (iatrogenic pneumothorax).

The 25 percent of hospitals with the worst scores are docked 1 percent of their Medicare reimbursements across all diagnosis related groups. The question is how long will it take for poorly scoring hospitals to put technologies and protocols in place to move them into a category where they will be saving patients’ lives and institutional resources?

Health Care-Associated Infections, a new report by the Leapfrog Group, a Washington, D.C., quality and safety group which represents employers, consumers and other purchasers, shows that there is still a significant incidence of serious infections that are often fatal. Long-time president and CEO Leah Binder report that while hospitals are making some progress and more are publicly reporting their rates of infection, data show that rates of infection are high and alarming.

This Leapfrog report represents the first in a series of five reports, derived from the 2015 Leapfrog Hospital Survey, which will examine key nationwide hospital safety and quality data collected from more than 1,500 hospitals in the United States. Analysis was provided by Castlight Health and reports will be made available at http://www.leapfroggroup.org/HospitalSurveyReport/. Some of the highlights Include:
• With 67 percent of New Hampshire hospitals reporting a CLABSI rate of zero, the state’s hospitals stood out as the safest. At the bottom were Maryland and Rhode Island, where there was a complete void of hospitals reporting a zero rate.
• The report found that 25 percent of hospitals met the Leapfrog Group’s standard infection ratio (SIR) of zero for CLABSI with the remainder having high central infection line rates.
• Sixty-seven percent of hospitals reported an SIR between zero and 1.0.
• Eight percent of hospitals had an SIR of above 1.0, with some 25 percent of hospitals having the group’s standard for urinary tract infection.

Through public reporting, The Leapfrog Group is credited with declining rates of CLABSI (hospitals reporting a CLABSI rate of zero increased to 25 percent in 2015, up from 18.8 percent in 2013), but at present, three-quarters of hospitals fail to meet Leapfrog’s standards, underscoring the need for increased quality improvement and transparency.

“This report highlights the risks associated with CLABSI and CAUTI infections, which can leave a patient susceptible to hospital readmission due to a hospital-borne infection, or sicker than when they arrived at the hospital,” says Kristin Torres Mowat, senior vice president of plan development and data operations at Castlight Health. “In our work with The Leapfrog Group, we strive to empower consumers with key quality and safety information to help them make informed health care decisions.”

A technological home run for CLABSI and pneumothorax reduction: ultrasound central line guidance
CLABSI and pneumothorax rank among the most expensive medical errors. According to the Centers for Disease Control (CDC), about 250,000 CLABSIs occur each year in the U.S. with estimated attributable mortality of 12 to 25 percent, and estimated cost of up to $56,000 per infection. Collapsed lung lengthens hospital stay by 4 to 7 days at an additional cost of up to $45,000 per case. The cost can soar far higher if the patient sues, with a recent study reporting malpractice payments of up to $6.9 million for central line-related injuries, such as pneumothorax, pulmonary artery rupture and air embolism.

Ultrasound-guided vascular access can help reduce — or even eliminate — dangerous complications of central-line placement. For example, a recent randomized study of 900 critical care patients reported that ultrasound-guided CVC lowered rates of pneumothorax to zero percent, compared to a rate of 2.4 percent for traditional landmark methods. The researchers also reported the following outcomes:

• A 100 percent success rate with ultrasound-guided CVC, compared to 94.4 percent in the landmark technique.
• A 1.1 percent rate of accidental carotid artery puncture with ultrasound, versus 10.6 percent with landmark methods.
• The ultrasound group also had significantly reduced blood-vessel access time, higher first-pass success and a 35 percent lower rate of CLABSI.

Proven safety practices
Evidence-based guidelines from many medical groups, including the CDC, recommend ultrasound-guided CVC due to its many safety benefits. Increasingly, leading hospitals around the U.S. are adopting a six-point bundle of safety practices to prevent CLABSIs that includes ultrasound guidance — and have seen rates of these infections drop as a result. The six-point bundle takes the established IHI five-point bundle and adds ultrasound guidance.

For example, after implementing this approach, Cedars-Sinai Medical Center in Los Angeles has seen striking reductions in CLABSIs, while White Memorial, also in Los Angeles, was able to achieve a rate of zero between January 2010 and August 2011, at the 353-bed hospital. The six-point bundle used consisted of these components:

1. Hand hygiene.
2. Maximal barrier precautions.
3. Chlorhexidine skin antisepsis.
4. Optimal catheter site selection.
5. Daily review of CVC necessity, with prompt removal of unneeded lines.
6. Ultrasound-guided central line placement (not part of the IHI bundle). It remains to be seen to what extent integrating procedures such as ultrasound-guided central line placement will help drive improvements in HAC scores, but the evidence of potential based upon reports from institutions has been compelling.

In addition, robust evidence from multiple peer-reviewed studies demonstrates the powerful role that ultrasound guidance can play in reducing — or even eliminating — medical harm from needle-based procedures performed to help patients heal. As Medicare continues to intensify the focus on improving hospital performance, it is incumbent upon health care institutions to implement the safety practices that have been shown to lead to the best outcomes.

Dan Conley is a freelance writer and contributor to HealthCare Business News. He writes frequently about infection control and technology.