Dr. Doug Woolley: CMS needs to get tough on hospital acquired infections

Hospital acquired infections will continue to be a problem until CMS takes a tough stand that makes hospitals, physicians and surgeons financially responsible for all the costs that accrue from an infection acquired within six weeks of discharge (it likely should be closer to 12 weeks for surgery patients).

As an orthopaedist who worked in two different hospitals during my 25 years in practice before retiring, my patients and I were confronted with three different spikes in acute infections of Total Joint Reconstruction over a 25 year career. In all three episodes, the hospital's response always was that it was a surgeon problem related to my technique (you must be doing something different that is causing your patients' infections, as the hospital has not changed any of its techniques or personnel).

In these infection spikes, there were some common but dangerous themes. If a surgeon reports an increase in infections it is assumed he is the problem. The real reason is that most surgeons (greater than 90 percent) do not report complications is they are unwilling to keep any accurate real-time data to criticize their results; especially not for complications as they might directly reflect on them. They do not realize that the agony of treating an infection for the patient and the physician is enough punishment. With accurate data, problems can not be ignored, and the root cause can be detected early before it spreads to other surgeons and services. The root cause for these infections always come back to money (in order to use less in resources, corners get cut).

The first episode was caused by buying surgical sponges from a cheaper supplier with poor quality control, and it was finally reported a year later after many more infections. The second episode occurred after it was decided that anyone in central supply could clean, sterilize and inspect high-speed bone cutting instruments. The cheaper, untrained staff [who worked] on afternoon and night shifts were found to not [have] completely disassembled the equipment after the neurosurgeons finally started to complain about their spike in infections. The final episode was a result of construction addition to the existing surgery suites in a different hospital. I complained that the filter system might be impacted by the construction debris, but the hospital denied that that could be the cause. Fortunately (or unfortunately, depending on your point of view), it rained shortly after that complaint and the roof leaked, allowing rain water to fall on a patient in the operating room. They then checked the filters and found them to be completely plugged. With the roof patched and increased frequency of filter maintenance, there were no further problems.

From my experiences there are some common problems that need to be addressed that will save a lot more money:

1. Every doctor and hospital needs to enter the 21st century and keep accurate, real-time data on their top five Medicare admissions that includes at a minimum: patient demographics (age, sex, diagnosis, co-morbidities etc.), treatment, average length of stay, discharge disposition, charges and complications/readmissions. This data gets submitted electronically with the bill six weeks after discharge; the hospital needs to do the same. To get paid the same day, the data must match from both sources. That way, no one can hide their outliers, and when patients get readmitted with the same patient demographics within six weeks of payment, immediately the hospital and doctor are notified that there will be no payment if the the complication or readmission is considered a breach in standard of care (infection rates should be no more than 0.6 percent, and if it becomes greater than 1.2 percent, then a reduced or no payment will occur). This would quickly reduce the abuse of home care services and readmission/complication rates.

2. Doctors and hospitals would have to start working together to take care of patients according to a national standard, as currently there are no standards, and every doctor and hospital has their own unwritten or unstated standards.

3. There can be no delay in payments as the doctor and hospital would have to work together to insure the data is correct, and no meddlesome third party could delay it as it is done electronically. Only errors would be kicked out. (I might be still working if I could have been paid within six weeks of my patient's discharge). Similarly, outcomes that reached a national standard would be paid at a higher rate, and those that fell below a certain standard would be reduced.

I could go on but, your article touched a nerve that physicians and hospitals have too long ignored. With the impetus for change that is sweeping through healthcare, documenting our results will provide more bang for the buck than EMRs ever could. Unfortunately customer (patient) satisfaction, teamwork and developing better systems are not as sexy and as expensive as a computer and new software.

Doug Woolley, MD, FRCS(c), FACS

The preceding letter was written in response to the April 20 article entitled "Infection control problems emerge at three VA hospitals".

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