By Elizabeth M. Dries, J.D.
Nearly half of Medicare patients in long term care hospitals (LTCHs) experienced adverse events or temporary harm events during their stay. The HHS Office of Inspector General (OIG) recommends that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and disseminate a list of potential harm events in LTCHs and that CMS include information about patient harm in its outreach to LTCHS. CMS and AHRQ concurred with the recommendations (OIG Report, No. OEI-06-14-00530, November 30, 2018).
Long term care hospitals. LTCHs are inpatient hospitals that specialize in treating long-term and clinically complex conditions, often with several acute and/or chronic conditions. LTCHs provide continued, acute-level care for patients following their stays in traditional acute-care hospitals. CMS oversees LTCHs compliance with a set of minimum quality and safety standards. There are approximately 400 LTCH providers in the Medicare Program. In addition, the Patient Protection and Affordable Care Act (ACA) established the quality reporting program for LTCHs, requiring those providers to submit data on selected quality measures including avoidable adverse events.
The review. The OIG reviewed the medical records for 587 Medicare beneficiaries admitted to LTCHs in March 2014, to establish a national incidence rate of adverse events and temporary harm events. The review was conducted in two stages. In the first stage, nurses screened records for possible harm events. In the second stage, physicians conducted a comprehensive review of the records flagged as containing possible harm events. Physicians identified the harm events, determined the level of harm, whether the events were preventable, and the factors that contributed to the event.
The OIG findings. The OIG found that 21 percent of Medicare patients in LTCHs experienced adverse events. An adverse event describes harm to a patient as a result of medical care or in a health care setting, including the failure to provide needed care. An adverse event indicates that the care resulted in an undesirable clinical outcome not caused by underlying disease. The four categories of adverse events include outcomes such as prolonging a patient’s LTCH stay or necessitating transfer to another facility; requiring life-saving intervention; resulting in permanent harm; and contributing to death. An additional 25 percent of patients experienced temporary harm events, which are patient harm that required medical intervention, but did not cause lasting harm. Patient stays in LTCHs present more opportunities for harm events because the stays are longer, but the number of harm events per patient day was similar between LTCHs and other post-acute-care settings and lower than in non-LTCH acute-care hospitals. Lastly, over half of the adverse events and temporary harm events were preventable. Preventable harm events were often related to substandard care (58 percent) and medical errors (34 percent). Additionally, 45 percent of harm events were found to be clearly, or likely not preventable, because the patients were already highly susceptible to harm due to other health conditions or poor overall health.
OIG recommendations. Based on its findings, the OIG recommended that AHRQ and CMS tailor their ongoing efforts to improve patient safety to address the specific needs of LTCHs. Specifically, the OIG recommended that AHRQ and CMS collaborate to create and disseminate a list of potential adverse events in LTCHs. Identification of patient harm is critical to the success of patient safety efforts, providing facility staff information to correct problems and reduce harm. AHRQ and CMS should use the list to highlight the most common types of harm in LTCHs.
Lastly, CMS should include information about potential events and patient harm in its quality outreach to LTCHs. Additional education tailored to LTCHS would further promote safe care practices and bring attention to the special needs of LTCH patients. The educational correspondence or material should include a definition of "adverse events," a list of potential adverse events for staff education on the range of harm that patients can experience, and evidence based best practices for reducing harm in the LTCH setting and best practices for improving staff identification and reporting of adverse events.
Sharing patient safety education tailored to LTCHs will complement the efforts underway for acute-care hospitals, SNFs, and rehab hospitals to raise awareness of adverse events and temporary harm events and to reduce harm in all inpatient settings. CMS and AHRQ concurred with the OIG’s recommendations.
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