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Wednesday, December 15, 2010

Simple sputum may assure reimbursement

One of the things that has been incorporated into our pneumonia protocol is that a sputum must be obtained before an antibiotic is initiated. Another is that on all ventilator patients a sputum must be obtained as soon as possible.

The purpose of both of these is to prove the patient did not have community acquired pneumonia upon admission. If these tests come up negative, and the patient is later diagnosed during the admission with pneumonia, it is then termed nosocomial pneumonia.

This is important, because in 2005 the Deficit Reduction Act passed by Congress requires the Centers for Medicare and Medicaid Services (CMS) to identify conditions that could have been prevented by implementing practices based on best practice evidence, and nosocomial pneumonia is one such instance.

Hospitals are now encouraged to screen patients on admission (hence the sputum sample being obtained) and procedures and therapies are ordered based on best practice evidence (this is accomplished via the pneumonia and ventilator extubation protocols*) are completed for that particular patient.

If proper procedures are not followed, and that patient develops an infection CMS believes could have been prevented, and no additional reimbursements will be given to the hospital to offset the cost of that admission.

This is why it is essential for hospitals to implement a program similar to Shoreline, which has a monthly Keystone meeting to review and analyze best practice evidence to improve order sets and clinical pathways based on the CMS core values. (You can read about core values here).

So you can see why it's so important to follow your hospitals order sets, protocols, and procedures to a tee. This is why many hospitals have anonymous people (like this) on duty who watch out to make sure everyone is washing their hands, or at least using hand sanitizer.

I know there have been instances here at Shoreline where CMS did not reimburse for a patient because a sputum sample was not obtained. Since the government is paying the bills, it has a right to tell you what to do in this way. I guess you can say this is a perfect example of every new law taking away another freedom.

Yet the ultimate goal here is to make sure nosocomial infections are minimized, and so the hospital gets full reimbursement for that patient. Not even close to the ideal system, yet that's the way it is when Uncle Sam has it's grip around an industry.

*Where I work order sets are called protocols. The reality is order sets and protocols are the opposite of one another.


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