Injury and Harm – How Do You Think Those Sound to a Jury?

CMS is soliciting public comments on its “Hospital Harms” Quality measures which include hypoglycemia, acute kidney injury, opioid related adverse events, and – Hospital-Acquired Pressure Injury.

The call for public comment closes on March 02, 2018.

CMS has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to develop four hospital-level electronic clinical quality measures (eCQMs) on “dimensions of patient harm or adverse patient safety events that can be improved with high quality care.” The point of this is to extract information directly from the hospital EHR that will calculate this “hospital harm” measure. The measure is one that is already reported by hospitals – which is the percentage of hospital-acquired pressure ulcers that develop or “worsen” while a patient is in the hospital. Pressure ulcers that go from unstageable to stageable are considered to have “worsened.”

The most dangerous statement in the documents that are part of this project is the statement by the National Quality Forum that hospital-acquired pressure ulcers are serious reportable events. It is simply not true that pressure ulcers are considered serious reportable events or “never events”. We have to get that falsehood corrected.

According to the Federal Register, Pressure ulcers are found under Subpart (F)(b) “Hospital Acquired Conditions” BUT not under Subpart (F)(c) “Serious Preventable Events”.  CMS Recognizes 4 Serious Preventable Events: 1) Leaving an object in the patient, 2) Performing the wrong surgery (wrong body part, wrong patient, wrong procedure), 3) Air embolism following surgery and 4) Administering incompatible blood products. Pressure ulcers are not on this list.

Pressure ulcers are “hospital-acquired conditions, (HACs) in the same category as surgical site infections and catheter-associated urinary tract infections. The legislative language which reduced payment to hospitals for pressure ulcers when they represented an additional major co-morbidity in hospitalized patients, identified pressure ulcers as high volume, high cost, important hospital-acquired complications for which prevention guidelines existed that can be implemented to improve quality of care. It did NOT say that they were “never events.” The NQF began using this language, and so did plaintiff’s lawyers, helped along by a lot of healthcare providers who thought they were doing the right thing.

This Harm quality measure presupposes that pressure ulcers worsen and transition from one numeric stage to another in the NPUAP staging system. I mean, what reasonable person wouldn’t think that, given that it’s called a STAGING system and anyone can count from 1 to 4. And that’s how plaintiff’s win pressure ulcer litigation against hospitals when patients are discharged with “stage 2 pressure ulcers” that are due to moisture and then later develop a stage 4 pressure ulcer that is completely unrelated, at a different facility. The hospital gets to write a big fat check. And don’t say that it’s just the insurance company. Those costs are passed along to everyone.

For goodness sake, at least don’t fall into the trap of believing that pressure ulcers are “never events.” Let’s hope that the momentum started at the Pressure Ulcer Summit by the AAWC will result in a staging system that reflects what we know about pressure ulcer pathophysiology. Clinicians and family members are now being charged with manslaughter as pressure ulcers are being linked to elder abuse in order to avoid caps on punitive damages after tort reform legislation was passed in many states. News flash – you can’t get murder insurance. Your malpractice insurance doesn’t cover you if you get charged with manslaughter in pressure ulcer case.

Nurses almost never suffer individual malpractice judgements for these cases. Physicians carry a pressure ulcer malpractice settlement around like a scarlet letter for the rest of their professional careers. But in the past, when you lost a frivolous case, it was “only money” (and your reputation, and your time). Now, your license and your livelihood are at stake. So, when you link the new terminology of “injury” with term “hospital HARM,” it’s time to either retire or engage. I’ve decided to engage. What have you decided to do?