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- Legislation/Regulation 1
- Newspaper/Magazine Article 3
- Special or Theme Issue 2
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- Press Release/Announcement 6
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United States of America
- United States Federal Government
- United States of America
Search results for "Department of Health and Human Services (HHS)"
- Department of Health and Human Services (HHS)
- Infectious Diseases
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Web Resource > Government Resource
QualityNet. Centers for Medicare and Medicaid Services.
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate the necessary changes. This website provides information and data collected from a Centers for Medicare and Medicaid Services financial incentive program reducing reimbursements to hospitals with elevated rates of hospital-acquired conditions.
Journal Article > Study
Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.
Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018;39:897-901.
The Centers for Medicare and Medicaid Services (CMS) nonpayment policy for health care–associated infections is widely viewed as a catalyst for infection prevention initiatives. This analysis of Medicare fee-for-service claims data shows that following nonpayment policy implementation, there was a substantial increase in claims in which central line–associated bloodstream infections and catheter-associated urinary tract infections were reported to be present on arrival to the hospital. According to this analysis, because CMS continued to reimburse hospitals for conditions present on arrival, the nonpayment policy did not have significant financial impact. The authors conclude that the nonpayment policy for health care–associated infections did not have its intended effect. A past PSNet interview discussed the potential benefits and limitations of insurers not paying for preventable complications.
Journal Article > Study
One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety.
Kossover-Smith RA, Coutts K, Hatfield KM, et al. Am J Infect Control. 2017;45:1018-1023.
Unsafe injection practices in health care settings have led to more than 50 disease outbreaks in the past 20 years. In this cross-sectional, voluntary survey across 8 states, 12% of responding physicians stated that needles were reused between patients in their workplace. Nearly 8% of physicians thought this was an acceptable practice. The authors discuss implications for the Center for Disease Control and Prevention's One & Only safe injection campaign.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
Jewett C. Kaiser Health News. May 9, 2017.
The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Journal Article > Government Resource
Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention.
Novosad SA, Sapiano MR, Grigg C, et al. MMWR Morb Mortal Wkly Rep. 2016;65:864-869.
Sepsis has been a significant focus of quality improvement initiatives. In this retrospective review, researchers sought to identify patient characteristics, risk factors, and infections that might inform sepsis diagnosis, treatment, and prevention efforts. The medical records of a random sample of 246 adult and 79 pediatric patients with codes for severe sepsis or septic shock across 4 New York hospitals were reviewed. Investigators found that 72% of patients had exposure to at least one health care factor during the 30 days prior to being admitted for sepsis or a medical condition requiring frequent health care contact. Pneumonia was the most frequently documented infection causing sepsis. They concluded that reducing sepsis will require an ongoing focus on infection prevention.
CDC Vital Signs. August 23, 2016.
CDC Vital Signs. March 3, 2016.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients. This toolkit was developed as part of a national implementation project to reduce rates of CAUTIs in hospitals and apply principles of the comprehensive unit-based safety program. The toolkit includes modules that focus on implementation, sustainability, and resources to help hospitals design CAUTI prevention efforts at the unit level.
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Journal Article > Review
U.S. compounding pharmacy-related outbreaks, 2001–2013: public health and patient safety lessons learned.
Shehab N, Brown MN, Kallen AJ, Perz JF. J Patient Saf. 2018;14:164-173.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Special or Theme Issue
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.
This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.
Special or Theme Issue
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-S141.
Articles in this special issue explore evidence developed from an AHRQ-funded initiative to reduce health care–associated infections (HAIs). Researchers examine epidemiological issues, disparities in HAI rates, quality improvement efforts, assessment tools, and how antibiotic stewardship programs influence HAI prevention and research.
Journal Article > Commentary
Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.
Hand hygiene adherence is a key target for improving patient safety. This guideline offers an overview of evidence-based strategies to monitor and promote hand hygiene, including resources developed by the Centers for Disease Control and Prevention and the World Health Organization's "5 moments" program. The authors provide detailed practice recommendations to increase hand hygiene compliance as a way to reduce health care–associated infections.
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.