By Christy Weaver, MSN, RN, ONCNAON
Executive Board Director

Since the Institute of Medicine’s (IOM) landmark report in 1999, health care organizations along with consumer and regulatory groups intensified their efforts to improve patient safety and quality. The publics’ awareness of health care cost, quality, and safety has increased the demands upon hospitals to improve their patient outcomes. Consumer groups have challenged health care organizations to provide a connection between the quality or outcomes of the care given and the proposed reimbursement received. Regulatory agencies continue to give direction to health care facilities through the initiation of enhanced rules and goals specifically targeted to improve patient safety and quality.

Responding to the IOM’s information the National Quality Forum (NQF) followed with a 2002 report that identified adverse events occurring in hospitals which were serious yet preventable.  The recommendations from the NQF were intended to raise the awareness and increase knowledge among principle stakeholders about negative preventable events. While the IOM report was not meant as a guideline for healthcare reimbursement, in 2005 Congress revised the method Medicare pays hospitals and adopted a list of preventable conditions for reduced reimbursement. In 2007 the Centers for Medicare and Medicaid Services (CMS) announced new criteria for its inpatient prospective payment system and began the implementation in October 2008.

The new payment system decreased reimbursement for hospitalized patients who acquired eight specific preventable conditions. The conditions termed “never events” are:

1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
4. Falls and Trauma including fractures, dislocations, intracranial injuries, crushing injuries and burns.
5. Stage III and IV pressure ulcers
6. Catheter-associated urinary tract infection
7. Vascular catheter-associated infection
8. Surgical site infections (mediastinits) after coronary artery bypass graft surgery.

Additional conditions and/or complications are currently being considered for reduced reimbursement starting in October 2009. Those hospital-acquired conditions consist of:

1. Surgical site infections after elective procedures including; Total knee replacement, Laparoscopic gastric bypass and Ligation/stripping of varicose veins.
2. Legionnaires disease
3. Glycemic control
4. Iatrogenic pneumothorax
5. Delirium
6. Ventilator associated pneumonia (VAP)
7. Deep Vein thrombosis/pulmonary embolism
8. Staphylococcus aureus septicemia
9. Clostridium difficile associated disease

For orthopaedic nurses several of these “never events” are conditions that our patients have the potential of obtaining during their hospital stay. Pressure ulcers, falls and trauma, VAP, vascular catheter-associated infections, and urinary catheter-associated UTI are also components of the Nurse Sensitive Indicators monitored by hospitals and utilized to benchmark nursing care quality. The remaining conditions are ones that we frequently observe and treat in our orthopaedic patient population.

Why are “never events” important to all orthopaedic nurses regardless of our individual role or responsibility? Patient quality is the primary reason. Many of these events are preventable with nursing care interventions we provide to our patients every day. Quality patient outcomes are not lofty organizational goals. They are everyday objectives all orthopaedic nurses must be cognizant and knowledgeable of so we can provide expert nursing care to our patients. Influence is gained through knowledge. When nurses are aware their units’ nurse sensitive indicator scores or their organizations’ percentile ranking on these preventable never events then we can begin to determine the appropriate patient interventions.

A second reason “never events” are important to all orthopaedic nurses is the reduced reimbursement to our employers. Using data from 2007, CMS reported 257,412 cases of Stage III and IV pressure ulcers which equaled an average increased cost of $43,180 per hospital stay. Falls and trauma was $33, 894 per hospital stay for 193,566 cases in 2007. Hospital acquired infections have an incredible financial impact upon health care organizations as vascular-catheter associated infections took the lead in the 2007 CMS data with $103,027 per hospital stay. At this point determining who will pay for the treatment cost of these reportable “never events” has not been clearly established. One vital factor is an accurate patient assessment upon admission and how well hospitals code the patient’s admitting diagnosis particularly any secondary diagnosis.

Hopefully your organization and/or nurse leaders share this critical patient data with your nursing colleagues. In today’s environment of enhanced transparency, many health care organizations post the information on their quality web site for employees and public to review. Do you know the incidence of pressure ulcers or falls in your hospital or department per 1,000 discharges? If you don’t have this data available then ask why. What type of preventive programs can your organization implement to reduce the incidence of preventable conditions? Does your organization utilize evidenced based policies or protocols you can implement to assess patients for these conditions? If not find out why, and if your hospital does then increase your knowledge of the interventions required to prevent “never events”. Patient quality starts at the bedside and understanding your department or facility’s data will assist orthopaedic nurses determine the objectives required to exceptional outcomes for our patients.

References:
     Mattie, A.S., Webster, B.L. (2008). “Centers for Medicare and Medicaid Services’ “Never Events’: An analysis and recommendations to hospitals. The Health Care Manager. 27(4),338-349.
     Studer Group. (2008). It’s Now or Never: Ensuring that Never Events Never Happen. Retrieved June 2009, from Studer Group.com.
     The Advisory Board Company, Nurse Executive Center. (2009). Safeguarding Against Nursing Never Events-Part 1. Retrieved July 2009, from Advisory Board.org.
     Thornlow, D.K., Merwin, E. (2009). “Managing to improve quality: The relationship between accreditation standards, safety practices, and patient outcomes. Health Care Management Review. 34(3), 262-272.