HOSPITAL ACQUIRED COMPLICATIONS. Shruti Scott, DO, MPH Department of Medicine UCI Hospitalist Program

HOSPITAL ACQUIRED COMPLICATIONS Shruti Scott, DO, MPH Department of Medicine UCI Hospitalist Program

HOSPITAL ACQUIRED COMPLICATIONS (HACS) A medical condition or complication that a patient develops during a hospital stay, which was not present on admission and associated with adverse consequences, including greater mortality and healthcare costs. Centers for Medicare and Medicaid Services (CMS) decided in 2010, that Medicare would not provide a reimbursement for a HAC because could reasonably be prevented through the application of evidence based guidelines. CMS implemented a process where hospitals would not be paid additional money for any of these complications. Medicare pays hospitals on the basis of Medicare Severity Diagnostic-Related Groups (MS-DRG), which better reflect the complexity of a patient s illness A three-tiered payment schedule: a base level for diagnosis, a second level adding money to reflect the presence of comorbidities and complications, and a third for major complications and comorbidities

NATIONAL HEALTHCARE SAFETY NETWORK CDC s National Healthcare Safety Network (NHSN) is the nation s most widely used healthcareassociated infection (HAI) tracking system NHSN provides facilities, states, regions and the nation with data needed to identify problem areas, measure progress of prevention efforts and ultimately eliminate HAIs. NHSN now serves over 17,000 medical facilities tracking HAIs that include acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehab hospitals, outpatient dialysis centers, ambulatory surgery centers and nursing homes.

CMS LIST OF HOSPITAL ACQUIRED COMPLICATIONS - Pressure ulcers - Falls - Venous thromboembolism - Healthcare Associated Infections (HAIs) - Surgical site infections (following CABG, orthopedic procedures, bariatric surgery) - Air embolism - Blood incompatability - Manifestations of poor blood sugar control - Foreign object retained after surgery

CMS LIST OF HOSPITAL ACQUIRED COMPLICATIONS 1. Pressure Ulcers: - nursing: take precautions to prevent them in our high risk patients: skin inspection, skin care, avoiding excessive moisture, turning and repositiong, air mattress, wound care - physicians: documentation about POA, optimizing nutrition 2. Falls: fall precautions, PT/OT consult, bed alarms

CMS LIST OF HOSPITAL ACQUIRED COMPLICATIONS 3. Venous thromboembolism - Without DVT ppx, the rate of developing venous thromboembolism can range anywhere from 10-80% - PE is one of the most common causes of preventable death in hospitalized patients - In more than 90% of cases of PE, the thrombosis generates in the deep veins of the legs DVT order set: evaluate their medical co-morbidities and surgical risk factors (if present) - Low VTE risk: ambulate TID around nurses station - Moderate VTE risk: anticoagulation preferred OR mechanical tx - High VTE risk: anticoagulation AND mechanical tx

HEALTHCARE ASSOCIATED INFECTIONS (HAI) - HAI, infections patients can get while receiving medical treatment in a healthcare facility are a major and often preventable threat to patient safety - HAI are defined as infections not present and without evidence of incubation at the time of admission to a healthcare setting (usually develop after 48 hours of admission) - Occurs in 4-5% of hospitalized patients - CDC estimates that there are 2 million cases of HAI each year - Treatment costs for HAI in the US can reach $4.5-11 billion dollars annually - Of these 2 million HAI cases, the CDC estimates that 20,000 patients die from HAI complications - Research shows that when healthcare facilities, care teams and individual doctors and nurses are aware of infection problems and take specific steps to prevent them, rates of some targeted HAIs (ex: CLABSI) can decrease by more than 70%

HAIS - CLABSI: central line associated bloodstream infection - CAUTI: catheter associated urinary tract infection - SSI: surgical site infection - VAP: ventilator associated pneumonia - Cdiff - MRSA - DVT/PE

CLABSI - CDC data indicate a 50% decrease in rates of CLABSI btw 2008 and 2014 - Results in thousands of deaths each year and billions of dollars in added costs - CLABSI rates at UCI - How can we prevent CLABSI: proper sterile placement, using chlorhexidine, nursing care and dressing changes, evalute the necessity of central lines daily and remove when no longer needed - What is the source of infection? When do you remove port or PICC?

CAUTI (SUPRAPUBIC AND URETHRAL) - The most common type of the HAIs - No change in overall CAUTI rate between 2009 and 2014 - The daily increase in UTI risk with indwelling catheters is 5% and there is a 3-10% daily bacteriuria risk, nearly every patient is colonized with bacteriuria within 4 weeks - Inappropriate use of indwelling catheters lies between 24-64% - More often, they are used without proper indications or continued longer than needed

CAUTI (SUPRAPUBIC AND URETHRAL) - How can we prevent CAUTI? Proper sterile technique in placement, evaluating the need for urinary catheters DAILY and removing them when not needed - What risks are associated with indwelling catheters? - How often do they need to be changed? - Intermittent catheterization: reduces risk of upper urinary tract deterioration, enables faster return to normal voiding, shorten hospital stay after surgery, reduces the risk of bladder stones by 20x compared with indwelling catheters

SSI - Leave that up to the surgeons! - Proper sterile technique - Good hand washing before surgery - Antibiotics within 60 minutes before surgery starts and the antibiotics should be stopped within 24 hours after surgery - 17% decrease in SSI related to 10 select procedures that are being tracked

VAP - Pneumonia that develops after 48 hours of endotracheal intubation - 5-15% of ventilated patients develop pneumonia Risk Factors (lots!) - age>55 - multiple trauma - Prolonged intubation - malnutrition - Agents that increase gastric ph - CKD - Aspiration - previous antibiotic use - Chronic lung disease - chest or upper abd sx - Mechanical ventilation for ARDS - use of muscle relaxants or steroids

VAP In 2014, Society of Healthcare Epidemiology (SHEA) and Infectious Diseases Society of America (IDSA) issued updated practice recommendations to reduce the risk of VAP. - Avoiding intubation when possible - Minimizing sedation, daily weaning trials - Facilitate early mobility - Utilize endotracheal tubes with subglottic secretion drainage ports - change the ventilator circuit only if visibly soiled or malfunctioning - Elevated head of bed to >30 degrees VAP prevention bundles: combining a core set of prevention measures into a bundle is a practical way to enhance care

C. DIFFICILE ASSOCIATED DIARRHEA (CDAD) - Spore forming, gram positive anaerobic bacillus that produces enterotoxin A and cytotoxin B - 15-25% of all antibiotic associated diarrhea are due to Cdiff - Between 2001 and 2012 the annual incidence of C diff increased by 42% and the incidence of multiply recurrent infection increased 188% - At UCI, rates of CDAD has been elevated - The incidence of community-associated C difficile infection (defined as disease in patients not hospitalized in the year prior to diagnosis) is also increasing - Poor prescribing practices put patients at risk for C difficile infections - More than half of all hospitalized patients will get an antibiotics at some point during their hospital stay, but studies have shown that 30-50% of antibiotics prescribed in hospitals are unnecessary or incorrect

CDAD - Symptoms: 3 or more watery stools (not on laxatives), fever, WBC>15-20K, abd pain, nausea - Antibiotics most frequently implicated in causing CDAD: FQ, Clinda, PCN, CS - Colonization vs true infection - NAP1 strain: larger quantities of toxin A/B and binary toxin - Up to 25% of patients experience recurrence of Cdiff infection within 30 days of completing treatment! - Diagnosis: June 20 th 2 step process - PCR (very sensitive and specific) and EIA for toxin (up to 98% sensitivity, up to 99% specificity) - 2 most important factors before checking for Cdiff: high pretest probability and OFF laxatives

MRSA: PREVENTION AND CONTROL - 100,000 invasive MRSA infections occur annually - The United States and Japan have the highest prevalence of MRSA - Infection prevention principles: proper hand hygiene and adherence to contact precautions - At UCI, active surveillance: all patients are screened for MRSA with nasal swab of nares - The anterior nares is a common site of MRSA colonization, positive in 73-93% - It positive, place in contact isolation to prevent spread to other patients - A large proportion of patients colonized with MRSA go on to develop infection - Since 2014, all patients (housewide) use chlorhexidine gluconate (CHG) solution (in place of soap and water) and/or CHG wipes - CHG is an antiseptic that has been shown to reduce the risk for infection in hospitalized patients - Many studies have shown that CHG bathing is associated with a 99.5% reduction in bacterial growth, which translates into reduced risk for hospital acquired infection

CMS LIST OF HOSPITAL ACQUIRED COMPLICATIONS - Pressure ulcers - Falls - Venous thromboembolism - Healthcare Associated Infections (HAIs): CLABSI, CAUTI, CDAD, MRSA - Surgical complications