An infected urinary sphincter prosthesis implanted 4 years ago is removed after it eroded into the urethra of a spinal cord injured patient. Cultures of the time of the explant are positive. Per institutional protocol, the Centers for Disease Control and the State Health Department are immediately notified by the hospital infection control officers about a “surgical site infection”. A patient treated elsewhere with an indwelling ureteral stent is taken to the operating room to complete the needed transurethral resection of a large bladder tumor. Pre op cultures are negative but 36 hours after admission a fever work up reveals a candida urinary tract infection. This is reported as a “catheter associated UTI” (CAUTI) since the continuous bladder irrigation catheter was still in after the resection. A 52-year- old male is admitted with urosepsis and an obstructing mid ureteral calculus. The patient is treated with antibiotics and taken to the operating room for stent placement. The management plan is for readmission for ureteroscopic stone extraction 2 weeks later. Shortly after the readmission for the definitive stone extraction, the hospital system red flags this appropriate follow up and pre-planned surgery as a reportable “unnecessary readmission”. Several of these occurrences also generated an automated “apology” letter from our hospital sent directly to the patient for these events.
The cases noted above are actual recent tales from our academic medical center. They are fairly common scenarios in the practice of urology and likely to be encountered by our urologic colleagues. At the present time most hospital systems are unable to sort out the planned readmissions scheduled from the unexpected or unnecessary ones. A urinary catheter and a UTI are an automatic match for a CAUTI in the world of electronic data mining when just looking at basic data. The strict definition of a CAUTI (infection develops when a catheter is indwelling for greater than 2 days) needs the interpretation of the clinical setting before this judgment is made.
In the Fall of 2008 Centers for Medicare and Medicaid Services (CMS) began to penalize providers for healthcare- associated infections, including CAUTI’s. CMS no longer pays for care associated with these conditions. Readmission penalties will affect over 2200 hospitals in FY 13. Although the CMS readmission penalties have been for a limited number of diagnoses to date (such as acute myocardial infarction, heart failure and pneumonia) CMS will be expanding the policy of Medicare nonpayment for preventable complications and readmissions as authorized by the Affordable Care Act. High on the list are other items that are beginning to receive scrutiny such as some very specific surgical site infections and 30 day postoperative readmissions.
A food for thought: a recent study in the New England Journal of Medicine found no evidence that this 2008 CMS policy of reducing payments for central catheter–associated bloodstream infections and catheter-associated urinary tract infections had any measurable impact on infection rates in U.S. hospitals.1 Likewise in a 2012 review, other authors found that the CAUTI rates determined by using claims data were much lower than epidemiologic surveillance would indicate, casting doubt on the accuracy of the data collection and reporting.2
Medicare.gov is now publishing very detailed hospital specific data on a variety of adverse outcomes as are many state health care agencies. Not only are the penalties in terms of failure to reimburse care costs associated with “preventable” complications here, public reporting on the web of these so called adverse outcomes is also ongoing.
There can be no argument with the goal of improving the care of patients and identifying preventable complications. It is shameful that proper judgment and clear assignment of cause and effect in this process seems to be lacking in the rush to implement changes to “improve health care”. Urologic surgeons beware as we are at the center of many issues relating to catheter associated UTI and planned readmissions. Monitor your hospital reporting data and work with your administration to ensure appropriate documentation and accurate analysis of these new reportable events. These not only impact care but can have dire financial consequences to the hospital’s well-being.
Leonard G. Gomella, MD Thomas Jefferson University Philadelphia, PA
1. Lee GM, Kleinman K, Soumeral SB et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med 2012;367(15):1428-1437.
2. Rosof B. The importance of accurate data in quality-of-care measurement. Ann Intern Med 2012;157(5):379-380.
© The Canadian Journal of Urology™; 20(1); February 2013