Clinical TopicsInfection PreventionPatient SafetyProfessional DevelopmentStaffingWorkplace Management

Nurses’ crucial role in preventing and documenting conditions not present on admission


By Eileen Shannon Carlson, JD, RN

Starting in October 2008, hospitals will receive lower Medicare reimbursement when inpatients contract hospital-acquired conditions (HACs) that they didn’t have on admission. Mandated by the Deficit Reduction Act of 2005, these policies to improve health care and reduce costs are consistent with the Pay-for-Performance and Value-Based Purchasing initiatives. In comments submitted to the Centers for Medicare & Medicaid Services (CMS) in December 2007, ANA affirmed its support for efforts to improve clinical quality and patient safety by reducing adverse events, emphasized the crucial role nurses play in preventing and documenting these conditions, and expressed concerns about adequate nurse staffing.

Hospital-acquired conditions
Congress defines HACs as high-cost or high-volume, reasonably preventable conditions, which classify to a higher-paying diagnosis-related group (DRG) when occurring as a secondary diagnosis. Each HAC must have a unique ICD-9-CM code for a complication or comorbidity (thus excluding ventilator-associated pneumonia and methicillin-resistant Staphylococcus aureus infection). When an HAC wasn’t present on admission and is the only (or first) such complication or comorbidity reported, the lower-paying DRG will apply.

CMS identified eight initial HACs for fiscal year 2009: an object left in surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection, decubitus ulcers, vascular catheter-associated infection, surgical-site infection (such as mediastinitis after coronary artery bypass graft), and falls and other injuries. CMS will review the HAC list annually and add other conditions as needed. ANA was pleased to see that patient falls are listed, as previous ANA comments supported their inclusion.

Present-on-admission indicator reporting
One of five codes will be used to indicate whether a diagnosis was present on admission: Y = Yes; N = No; U = documentation is insufficient to determine; W = clinically unable to determine; and I = unreported/not used (similar to a blank). Each hospital must develop its own system for determining whether a diagnosis was present on admission, based on the complete patient record. Some controversy and confusion have emerged over whether nursing documentation can be used in this determination. ANA has urged CMS to clarify this issue, emphasizing the importance of timely, detailed, accurate assessment and documentation to the nursing profession.

In public discussions, CMS also referred to physicians as having sole responsibility for patient diagnosis, admission, and billing. ANA’s comments affirmed that nurse practitioners (NPs) may qualify as Medicare providers, and NPs customarily diagnose patients.

The role of safe, appropriate nurse staffing
Nursing care is an integral component of every inpatient’s hospital stay, and nurses are the only healthcare professionals with direct bedside, 24-hour accountability for ongoing patient care. Nurses working on the front lines provide preventive and ongoing care, with many nursing interventions specifically designed to prevent HACs. Research published in the Journal of Advanced Nursing has shown a link between a 10% increase in RN employment and 6 fewer deaths per 1,000 discharged patients. A 2007 study by the National Database of Nursing Quality Indicators shows that greater RN participation in patient care leads to fewer complications, such as falls and pressure ulcers.

Appropriate nurse-patient ratios are a crucial component of safe, adequate nurse staffing. The ANA is concerned, however, that hospitals may decrease nurse staffing because of declining reimbursements for HACs. To prevent this, ANA urges that hospitals recognize the value of safe, appropriate nursing care by including within their quality evaluations the National Quality Forum’s nursing sensitive indicators of nursing hours per patient day, staff mix, and RN turnover.

With the nursing supply projected to drop to 36% below requirements by 2020, now is the time to invest in the future of our country’s health care by investing in nursing education and training. Due to lack of funding, in 2006, the Health Resources and Services Administration had to turn away 85% of applications for the Nursing Education Loan Repayment Program and 96% of Nurse Scholarship Program applicants.

Eileen Shannon Carlson is Associate Director of Government Affairs for ANA.

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