Hospital Acquired Conditions: Present on Admission APIC Chapter 26 Carol Jacobson, RN October 1, 2008

OHA Role Federal Communicate and provide comments to the American Hospital Association (AHA) State – Rely on input from hospitals Quality Institute Collaboratives OPSI HAI Committee for HB197 Chasing Zero CDI – OSU and CDC OHICU – CLBSI

Section 5001(c) of Deficit Reduction Act of 2005 Requires CMS to identify at least two conditions by October 1, 2007, that are (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) Reasonably prevented through the application of evidence ‑ based guidelines.

Affected Hospitals The Present on Admission (POA) Indicator requirement and Hospital-Acquired Conditions (HAC) payment provision only apply to: Inpatient Prospective Payment Systems (IPPS) Hospitals.

EXEMPT For POA/HAC 1. Critical Access Hospitals (CAHs) 2. Long-term Care Hospitals (LTCHs) 3. Maryland Waiver Hospitals 4. Cancer Hospitals 5. Children's Inpatient Facilities 6. Inpatient Rehabilitation Facilities (IRF) 7. Psychiatric Hospitals

CMS Hospital Acquired Conditions FY 2008 Hosp. Acquired Injuries (i.e. falls/burns/ fractures... (19) Mediastinitis CABG DRIVEN BY PRESENT ON ADMISSION CODES

Conditions Selected FY 2008 Serious Preventable Events Object left in during surgery (998.4 CC and 998.7) Air embolism (999.1 MCC) Blood incompatibility (999.6 CC) Pressure Ulcers ( & CCs; MCCs) Falls and Trauma – Fractures, Crushing Injuries, Dislocations, Intracranial Injuries, Electric Shock, and Burns

Conditions Selected FY 2008 Catheter Associated Urinary Tract Infection, ( CC & one of the following specific infection codes: 112.2, , , 590.2, 590.3, , , 590.9, 595.0, 595.3, 595.4, , , 595.9, 597.0, , 599.0) Vascular Catheter Associated Infection ( CC) Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery (519.2 MCC & )

Additional Conditions for FY2009 Poor Glycemic control Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE) (DVT: CCs; PE: & MCCs) Expansion of SSI to include Bariatric & certain orthopedic surgeries

Conditions needing further analysis Methicillin Resistant Staphylococcus Aureus (MRSA) ( Clostridium difficile-Associated Disease (CDAD) ( CC) Wrong Surgery (wrong body part, wrong patient, wrong surgery performed on a patient)

Other Payers CMS sent letter to state Medicaid offices providing information about how states can adopt the same HAC To date Ohio Medicaid has not announced concurrence Third party payers – many have already adopted similar non-payment policies

POA Reporting Requirements POA indicator is based not only on the conditions known at the time of admission, but also include those conditions that were clearly present but not diagnosed, until after the admission took place. POA is defined as present at the time the order for inpatient admission occurs.

POA Assignment POA indicator applies to principal diagnosis, secondary diagnoses, external cause of injury codes. Inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.

Reporting options and definitions: “ Y” - condition Present on Admission “N” - condition not explicitly documented on admission “U” - insufficient/no information in the record “W” - clinically undetermined “1” - unreported/not used – exempt from POA reporting

POA Indicator Timeline Effective October 1, 2007 CMS will collect POA Oct– Dec 2007 Voluntary – no link to payment January 1, 2008 hospitals required to collect POA April 1, 2008 CMS will reject entire claim if POA coding is not present Oct. 1, 2008 CMS cannot assign a case to higher DRG if hospital acquired

Impact of Payment Adjustment for Hospital Acquired Condition Inpatient PPS Columbus Wage Adjusted Rate$ DRG 195Simple pneumonia w/out CC Weight Payment $ DRG 194Simple pneumonia w/CC Pressure Ulcer - Elbow $ Potential Loss$ (977.36)

2008 HAC Associated Costs Hospital Acquired Condition # Cases/cost hospital stay (FY 2007) Catheter-associated UTI 12,185 cases/$44,043 Vascular Catheter- associated Infection 29,536 cases/$103,027 Surg Site Infection – Mediastinitis 69 cases/$299,237

Future HAC Associated Costs Hospital Acquired Condition # Cases/cost hospital stay (FY 2007) SSI – Total Knee Replacement 539 cases/$63,135 SSI – Lap Gastric Bypass & Gastoenterostomy 208 cases/$180,142 SSI – Varicose Vein Ligation/Stripping 3 cases/$66,355

Future HAC Associated Costs Hospital Acquired Condition # Cases/cost hospital stay (FY 2007) Ventilator Associated Pneumonia (VAP) 30,867 cases/$135,795 Staph aureus Septicemia 27,737 cases/$84,976 C. difficile-associated Disease (CDAD) 96,336 cases/$59,153 Legionnaire's Disease351 cases/$86,355

Best Source of Information Provider (Physician) documentation at time of Admission ED Notes History and Physical Progress Notes Admitting Notes

How to improve payments Communicate, Communicate, Communicate! Build Awareness Provide guidance Standardize Procedures Monitor Implementation Close the loop

New HB 197 measures Core Measures PN-2 Pneumococcal vaccine PN-7 Influenza vaccine SCIP-inf-1 Prophylaxis Atx 1 hr pre-incision SCIP-inf-2 Proph. Atx selection SCIP-inf-3 Proph. Atx discontinuation SCIP-inf-1 (Pediatric population)

Proposed HB 197 measures CDC Measures Surgical site infection CABGw/both surgical site + donor site incision) Caesarian Section Knee prosthesis Influenza vaccine for HC workers Catheter Associated Bloodstream infection in ICU pts (pediatrics) Surgical Site infections (pediatrics)

New HB 197 measures Other Measures Hospital acquired Clostridium difficile Hospital acquired MSRA + MSSA bacterimia Handwashing Program Infection Control staffing

Questions? Carol Jacobson