It's a new way to push for patient safety: Don't pay hospitals when they commit certain errors. Medicare will start hitting hospitals where it hurts in October, and other insurers are hot on the trail.
That has the nation's hospitals exploring innovative programs to prevent injury and infection: Hand-washing spies. Surgical sponges that sound an alarm if left in the body. Even a room sterilizer that promises to wipe out bacteria left lurking on bedrails.
"Money talks," says Dr. Steven Gordon, infectious disease chief at the Cleveland Clinic Foundation. "Every hospital CFO, this gets their attention."
And patients' first sign that something is changing may involve lessening of a big indignity: Today, one in four hospitalized patients is outfitted with a urinary catheter. The tubes trigger more than half a million urinary tract infections a year, the most common hospital-caused infection.
Yet many patients don't even need catheters — they're an automatic precaution after certain surgeries — and many who do have them for days longer than necessary. Why? The University of Michigan reported the first national study of catheter practices last month, finding nearly half of hospitals don't even keep track of who gets one. Fewer than one in 10 hospitals does a daily check to see if the catheter is still needed, a simple but proven infection-reducing system.
With those infections topping Medicare's do-not-pay list, Gordon says hospitals already are beginning to get choosier about who needs catheters, and to yank them faster.
Even when a hospital makes a preventable error, it still can be reimbursed for the extra treatment that patient will now require. Some errors can add $10,000 to $100,000 to the cost of a patient's stay.
Beginning Oct. 1, Medicare no longer will pay those extra-care costs for eight preventable hospital errors, including catheter-caused urinary tract infections, injuries from falls, and leaving objects in the body after surgery. Nor can hospitals bill the injured patient for those extra costs.
Next year, Medicare will add three more errors to the no-pay list; ventilator-caused pneumonia and drug-resistant staph infections are top candidates.
Medicare, which insures about 44 million elderly and disabled people, estimates the move will save the government about $190 million over five years.
It also sparked a movement: Private insurance giants like Aetna are moving to make hospitals absorb the cost of serious errors. Pennsylvania last month said it would follow Medicare's example and stop Medicaid payments, too. The American Hospital Association is urging members to voluntarily quit billing for treatment of serious errors, and hospitals in a number of states, from Minnesota to Vermont, have announced they will.
Many hospitals already were trying to improve patient safety for a bigger reason — to prevent suffering and death — and a question is whether making them literally pay for mistakes will spur greater improvements. But some novel attempts are under way:
— A standard mop-and-bucket cleaning leaves bacteria in hospital rooms, especially on electronic equipment that janitors hesitate to touch. So the Wellmont Health System in Kingsport, Tenn., is testing a portable machine that sterilizes a closed room by spewing out vaporized hydrogen peroxide that reach into every nook and cranny.
STERIS Corp.'s VaproSure is proven to eliminate tough germs; it has long been used in sterile manufacturing facilities, and even helped clean buildings tainted in the 2001 anthrax attacks.
But doctors, nurses and others bring new germs into rooms every time they enter, raising the question of whether sterilizing between check-ins will really lead to fewer infections.
"There's no question they can sterilize a room," Wellmont chief executive Dr. Richard Salluzzo says of the $180,000 machines. "Has it prevented infection? We don't have the answer to that yet."
He hopes to have enough data to tell by year's end.
— Nurses count surgical sponges to make sure they're all out before a patient is sewn up, but every hospital occasionally misses some. In University of Michigan operating rooms, doctors are testing sponges tagged with bar code-like radiofrequency chips. Wave a wand and a beep sounds if a sponge is still in the wound. Or, nurses can drop used sponges into a "smart" bucket that counts how many are missing.
"We've had a long history in medicine of this problem continuing to occur no matter what kind of very careful steps we've devised," says clinical affairs chief Dr. Darrell Campbell, a well-known patient safety specialist. "We want to get to zero."
— In U-Michigan's hospital halls, physician assistants are assigned to spy to tell if fellow workers wash hands both when entering and exiting patient rooms. Workers are better at remembering on the way in, but they don't want to carry germs back to the nurses' station or elevator buttons, either, Campbell notes. Some bugs can live on cool hospital surfaces for weeks.
There is some concern that the no-pay push could make hospitals try to hide certain errors, or just trade one problem for another. Pull a urinary catheter too soon, for example, and a fragile patient may fall going to the bathroom, says Michigan's Campbell.
"I don't know how much is really preventable," adds the Cleveland Clinic's Gordon. "We want to chase zero, but we'll probably never get to zero."