Patient Safety Tip of the Week


April 22, 2008

CMS Expanding List of No-Pay Hospital-Acquired Conditions






Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for eight conditions originally announced in a final rule last year or any conditions added to the list, if they were acquired during the hospital stay. The first eight hospital-acquired conditions (HAC’s) were:



CMS is proposing to expand the list of conditions ( to include:




Comments on the proposed rule will be accepted by CMS through June 13, 2008 a final rule is expected on or before August 1, 2008.



The proposed changes are contained in a 1205-page document CMS-1390-P that is not easy reading! However, it does contain useful information about the conditions selected. CMS does utilize specific criteria in the process of selecting candidates as hospital acquired conditions to be included on the list. They must be of either high cost or high volume or both. They must have an ICD-9-CM diagnosis code that clearly identifies them. And there must be evidence in the literature that the complication is reasonably preventable through application of evidence-based guidelines. The document includes tables that provide links to at least some of the evidence base for preventability of each of the proposed conditions.


We anticipate that at least 7 of the proposed 9 additional HAC’s will be in that final rule. We suspect that the comments submitted may likely lead to removal of delirium and Legionnaire’s disease from the list.



The problem with delirium is not that it’s not important to maintain surveillance for delirum but rather in what the evidence base says about interventions. We discussed delirium briefly in our March 4, 2008 Patient Safety Tip of the Week “Housestaff Awareness of Risks for Hazards of Hospitalization”. We noted that if the Hazards of Hospitalization Questionnaire tool developed by the authors (Fernandez 2008) can be validated in several settings or populations, it has tremendous potential to help us prevent complications such as delirium. Not only is delirium associated with increased morbidity and mortality, but it is also associated with prolonged lengths of stay and excess costs (Leslie et al. 2008). At least 2 studies have demonstrated that multifactorial interventions targeted at elderly inpatients at risk for delirium may shorten hospital length of stay, reduce duration of delirium, and reduce mortality (Lundstrom et al. 2005; Naughton et al 2005). The Lundstrom study showed that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients. The Naughton study showed that a multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings. So there does appear to be some evidence that such programs make sense from quality, patient safety, and financial perspectives. However, the interventions are not likely to significantly reduce the number of patients identified with delirium. In fact, a good tool might actually increase the number identified. There are also many factors that are truly not under control of the hospital and staff that may precipitate delirium. So our feeling is that hospitals should not be penalized unfairly for the occurrence of delirium. (See also our 10/14/08 Patient Safety Tip of the Week “Managing Delirium” for more on why you should have a program focusing on delirium.)




The issue with Legionnaire’s disease is the problem of attribution to the hospital or the community. A clearcut outbreak in a hospital that can be traced to problems with a pipe system, etc. certainly should merit no pay. The problem is more likely to arise with isolated cases of Legionnaire’s, which will probably be more common in the long run. In those cases, it may be very difficult to determine whether the patient was exposed prior to or after admission to the hospital. We think that CMS and the hospitals would have a difficult time adjudicating such cases.



So what should hospitals be doing in the interim? Our November 2007 “What’s New in the Patient Safety World” column pointed out an excellent paper by ECRI Institute on how to get ready for the CMS final rule on Hospital-Acquired conditions. It gives good recommendations on putting together a multidisciplinary team to get ready for this. There is also a video and podcast available. Now, more than ever, hospitals need to prevent costly complications because they will bear the full burden for most of those excess costs. And for the newly added conditions, you’ll want to make sure you have programs such as the IHI VAP Bundle, and the Peter Pronovost-like checklists to help prevent central-line associated infections, and the Surgical Care Improvement Project (SCIP) bundle, a good system for determining DVT risk and implementing appropriate prophylaxis, fall and decubitus risk assessments, a Foley catheter use reduction program, and a good overall infection control plan. Make good use of standard order sets, trigger tools, and CPOE with clinical decision support. We also expect to see more “proceduralists” working at hospitals to reduce complications such as pneumothoraces.









Centers for Medicare & Medicaid Services. [CMS-1390-P]. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians.



Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House Staff Member Awareness of Older Inpatients' Risks for Hazards of Hospitalization. Arch Intern Med. 2008;168(4):390-396



Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch Intern Med 2008; 168(1): 27-32.



Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R, Mylotte JM. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005; 53(1):18–23



Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005; 53(4): 622–628











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