May 2014

How Can Hospitals Prevent Healthcare-Associated Infections?

By Brian McCurdy, Senior Editor

Acknowledging the prevalence of healthcare-associated infections, a recent study in the New England Journal of Medicine supports the notion that hospitals should consider expanding surveillance and prevention activities against such infections, particularly those caused by Clostridium difficile.

   The authors conducted a survey of 183 hospitals, finding that of 11,282 patients, 452 (4 percent) had one or more healthcare–associated infection. Out of 504 such infections, the study notes 21.8 percent were pneumonia, 21.8 percent were surgical-site infections and 17.1 percent were gastrointestinal infections with Clostridium difficile the most commonly reported pathogen.

   As Nicholas Giovinco, DPM, says, old-fashioned hand washing is an effective way to prevent infection and washing hands before and after patient interaction is a must. Although the innovative tracking solutions and large data algorithms are greatly augmenting the surveillance of hospitals and living communities, he notes these are not in everyday use yet but may be in the future.

   Ryan Fitzgerald, DPM, notes a paucity of data on how best to perform surveillance for C. difficile infections, either in healthcare or community settings. He notes the Centers for Disease Control and Prevention (CDC) has recommended a case definition for surveillance that requires the presence of diarrhea or evidence of megacolon, and either a positive laboratory diagnostic test result or evidence of pseudomembranes demonstrated by endoscopy or histopathology. Dr. Giovinco concurs, saying one should take seriously issues of increased bowel activity and the onset of diarrhea.

   Testing for C. difficile or its toxins occurs via an assay test, which Dr. Fitzgerald notes yields historically high rates of both false positive and false negative test results. Although newer tests are improving the sensitivity of the tests over immunoassays, their specificity remains relatively low, according to Dr. Fitzgerald, an Assistant Professor of Surgery at the University of South Carolina School of Medicine-Greenville in Greenville, S.C.

   The CDC’s Clinical Practice Guidelines for Clostridium difficile Infection in Adults recommend education on hygiene and contact isolation appropriate to the level of the contaminant to reduce the chance of infection, according to Dr. Fitzgerald. Additionally, he notes the judicious use of antibiotics and attempts to minimize the frequency and duration of antimicrobial therapy, and the number of antimicrobial agents prescribed can greatly reduce the risk of C. difficile.

   What other infection prevention protocol should hospitals initiate? Dr. Giovinco supports having more biocompatible solutions to promote healthy topical flora. Similar to having a probiotic for the gut, he advocates looking into methods of maintaining skin and surface colonization with competitive bacteria that are less opportunistic.

   “Trying to maintain a sterile hospital environment is not paying off like it should be,” says Dr. Giovinco, the Director of Education of the Southern Arizona Limb Salvage Alliance (SALSA).

   Dr. Fitzgerald emphasizes the necessity of developing improved screening tests with a greater level of sensitivity and specificity to more accurately identify those patients suffering C. difficile infection. He says this allows early and aggressive management of this disease process. Dr. Fitzgerald notes other solutions include improved surveillance modalities and improved efforts at cleaning and disinfection.

   “Ultimately, enhanced compliance by healthcare providers, patients and visitors with current recommendations and protocols can prevent the spread of infectious pathogens,” maintains Dr. Fitzgerald.

Survey Compares Self-Employment With Institutional Healthcare Employment

By Brian McCurdy, Senior Editor

Is it better to work at a larger healthcare institution or be self-employed in private practice? A recent survey on Medscape points to some reasons why doctors may choose one type of practice over the other.

   As the survey notes, 38 percent noted that they sought employment due to the financial challenges of private practice. The factors for this decision included not having to worry about billing, office management or administrative issues. On the other side of the fence, the survey noted that self-employed doctors have autonomy but less security, and are somewhat more satisfied with their situation than employed doctors.

   William Fishco, DPM, calls his business a “mom and pop” podiatry practice that consists of him and two employees. He is able to control how busy the practice is and his staff does not overbook the schedule. Accordingly, Dr. Fishco says he does not have to rush through patients or feel overwhelmed, and feel the pressure that “irate patients are barking in the waiting room.”

   “My philosophy is that the patient’s time is just as important as mine and I rarely run more than five minutes behind,” says Dr. Fishco, who is in private practice in Phoenix. “Most of my patients don’t even have time to sit down in the waiting room before being set up in a treatment room. I hear from my patients that they commonly wait one to two hours to see their other specialists.”

   Dr. Fishco says his patients still have the feeling that they are family and that the staff knows who they are rather than as just a medical record number. He cites his autonomy in delivering healthcare, saying “The last thing that I want is some MBA guy in a suit telling me that I have to see more patients, use less expensive products or do more surgery.” Other benefits for Dr. Fishco are having control of his overhead and business decisions, and having the potential of unlimited income as he is not bound by a salary.

   Dr. Fishco does acknowledge advantages of the employed setting, typically a hospital or multispecialty facility, saying obtaining ancillary testing or subspecialty care may be streamlined, which is optimum for the patient. He says one drawback to this type of practice is a lack of selection of a physician for the patient. From the self-employed setting, he notes patients get more personalized care and more quality time with the physician, saying it ultimately boils down to the individual physician and his/her ability to communicate and deliver services to the patient.

What Does The ICD-10 Delay Mean For DPMs?

By Brian McCurdy, Senior Editor

The deadline for conversion to ICD-10 coding has lingered on the horizon for podiatrists. However, they now have more time to prepare thanks to a new law that delays the Department of Health and Human Services’ implementation of ICD-10 until at least October 1, 2015.

   The original deadline was October 2014. An article in Modern Healthcare notes that the American Medical Association, the Medical Group Management Association and other groups had expressed serious concerns about the feasibility and costs of meeting the deadline while the American Hospital Association strongly opposed delaying ICD-10.

   Barbara Aung, DPM, notes that the delay gives a grace period for those who were not ready for ICD-10 in their practices. On the other hand, she says many have spent time and money to learn the new codes and documentation, getting computer systems and billing offices ready, and training staff. While the delay means the time and money have not really been lost, she says the delay “can be a letdown as we may feel we are ready to make the change.”

   Dr. Aung cautions that it really would be a speculation as to when the ICD-10 will be required but one can assume that the deadline will be Oct. 1, 2015.

   “There is no crystal ball to know if the government will change the deadline again,” says Dr. Aung, who is in private practice in Tuscon, Ariz., and is the Co-Director of the Wound Center at Carondelet St. Joseph’s Hospital in Tucson, Ariz. “Their stance appeared firm after the initial delay in 2013 but with this second delay, I probably won’t be as adamant that the deadline is in stone.”

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