tracking-hospital-acquired-conditions

# Tracking Hospital-Acquired Conditions

Monitors and documents hospital-acquired infections, pressure injuries, and other preventable conditions to reduce harm and maintain regulatory compliance.

## Why This Skill Exists

Hospital-Acquired Conditions (HACs) are preventable injuries and infections that occur during hospitalization and were not present on admission. CMS identifies specific HACs for which hospitals receive no additional payment, and the HAC Reduction Program penalizes the worst-performing quartile of hospitals with a 1% reduction in total Medicare payments. This represents millions of dollars annually for most hospitals and directly ties patient safety to financial viability.

The 14 CMS-designated HACs include catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), surgical site infections, falls with injury, pressure injuries stage III+, and several iatrogenic conditions. The National Healthcare Safety Network (NHSN) provides standardized definitions and reporting requirements. Hospitalists play a central role in HAC prevention through daily device assessments, evidence-based bundles, documentation of present-on-admission (POA) status, and early recognition and escalation of developing conditions.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

Before tracking or reporting HACs, confirm:

1. What **HACs is the institution required to track** — all CMS-designated conditions or a subset? *(Default: All 14 CMS HACs)*
2. What is the patient's **present-on-admission (POA) documentation** for each relevant condition? *(Default: POA must be assessed and documented within 24 hours of admission)*
3. Does the patient have **indwelling devices** — Foley catheter, central line, ventilator? *(Default: Review active orders and device inventory)*
4. What is the patient's **Braden Scale score** for pressure injury risk? *(Default: Nursing completes on admission and per protocol)*
5. What **antibiotic stewardship** measures are in place for infection prevention? *(Default: Review current antibiotic orders and indications)*
6. Are there **isolation precautions** in place? *(Default: Check for MDRO colonization, C. diff, or other contact/droplet/airborne indications)*
7. What is the **hospital day** and how long have devices been in place? *(Default: Document device day counts)*

### Documents to Request

- Admission skin assessment with POA wound documentation (photos if available)
- Braden Scale score (admission and most recent)
- Device inventory with insertion dates (central line, Foley, ventilator)
- Infection control surveillance reports
- Antibiotic utilization report (current and cumulative days)
- Nursing assessment for CAUTI, CLABSI, and pressure injury prevention bundles
- NHSN definitions reference for HAC identification
- Prior admission HAC history

---

## Step 1: CMS Hospital-Acquired Conditions Reference

| HAC Category | Condition | Prevention Strategy |
|-------------|-----------|-------------------|
| **HAC 1** | Foreign object retained after surgery | Surgical count protocols |
| **HAC 2** | Air embolism | Central line insertion/removal protocols |
| **HAC 3** | Blood incompatibility | Two-person verification for transfusions |
| **HAC 4** | Pressure injury Stage III/IV | Braden Scale assessment, repositioning, nutrition |
| **HAC 5** | Falls with injury | Morse Fall Scale, multifactorial prevention program |
| **HAC 6** | CAUTI | Catheter removal protocols, daily necessity review |
| **HAC 7** | CLABSI | Central line bundle, daily necessity review |
| **HAC 8** | Poor glycemic control (hypoglycemia) | Insulin protocol management |
| **HAC 9** | DVT/PE after hip/knee replacement | VTE prophylaxis protocol |
| **HAC 10** | Iatrogenic pneumothorax | Ultrasound-guided procedures |
| **HAC 11** | SSI following certain procedures | Antibiotic prophylaxis, sterile technique |
| **HAC 12** | SSI after cardiac procedures | Perioperative bundle compliance |
| **HAC 13** | Vascular catheter-associated infection | CLABSI bundle |
| **HAC 14** | C. difficile infection | Antibiotic stewardship, hand hygiene, isolation |

---

## Step 2: Daily Device Assessment (CAUTI and CLABSI Prevention)

### CAUTI Prevention Bundle
Assess daily and document:

| Element | Assessment | Action if Criteria Not Met |
|---------|-----------|---------------------------|
| **Indication** | Does the patient still need a Foley? | Remove if no valid indication |
| **Valid indications** | Acute urinary retention, critical illness with UOP monitoring, perioperative (< 24h post-op), sacral/perineal wound with incontinence, end-of-life comfort | All other indications = remove |
| **Day count** | How many days has the catheter been in place? | Flag at day 3; strongly advocate removal by day 5 |
| **Catheter care** | Securement device in place? Bag below bladder? No dependent loops? | Correct deviations immediately |
| **Urine assessment** | Appearance, UA/culture only if clinical signs of infection present | Do NOT order UA/culture routinely — leads to inappropriate treatment of asymptomatic bacteriuria |

### CLABSI Prevention Bundle
Assess daily and document:

| Element | Assessment | Action |
|---------|-----------|--------|
| **Indication** | Does the patient still need a central line? | Convert to peripheral access if feasible |
| **Day count** | How many days has the line been in place? | Document; no arbitrary removal date, but daily reassessment |
| **Dressing** | Clean, dry, intact, dated? | Change if soiled, loosened, or > 7 days (transparent) |
| **Access points** | Caps changed per protocol? Scrub the hub? | Reinforce nursing compliance |
| **Site assessment** | Signs of infection (erythema, drainage, tenderness)? | If suspected: blood cultures, consider removal |

---

## Step 3: Pressure Injury Prevention

### Braden Scale Assessment

| Factor | 1 (Highest Risk) | 2 | 3 | 4 (Lowest Risk) |
|--------|-------------------|---|---|------------------|
| **Sensory perception** | Completely limited | Very limited | Slightly limited | No impairment |
| **Moisture** | Constantly moist | Very moist | Occasionally moist | Rarely moist |
| **Activity** | Bedfast | Chairfast | Walks occasionally | Walks frequently |
| **Mobility** | Completely immobile | Very limited | Slightly limited | No limitation |
| **Nutrition** | Very poor | Probably inadequate | Adequate | Excellent |
| **Friction/Shear** | Problem | Potential problem | No apparent problem | — |

**Total score range: 6-23**
| Score | Risk Level | Interventions |
|-------|-----------|--------------|
| ≤ 9 | Very high risk | Specialty mattress, Q2h repositioning, nutrition consult, wound care consult |
| 10-12 | High risk | Pressure redistribution mattress, Q2h repositioning, nutrition optimization |
| 13-14 | Moderate risk | Standard pressure-reducing mattress, repositioning schedule, skin inspection |
| 15-18 | Mild risk | Standard mattress, encourage mobility, moisture management |
| 19-23 | No significant risk | Standard precautions |

**Key interventions for at-risk patients:**
- Reposition every 2 hours (document position changes)
- Heels off the bed (use heel elevation devices)
- Nutrition optimization (protein intake ≥ 1.2-1.5 g/kg/day for wound healing)
- Moisture management (incontinence care, barrier creams)
- Daily skin inspection with documentation of all findings

---

## Step 4: C. difficile Prevention

| Prevention Element | Action |
|-------------------|--------|
| **Antibiotic stewardship** | Review all antibiotics daily; narrow spectrum when possible; discontinue when treatment course complete |
| **High-risk antibiotics** | Fluoroquinolones, clindamycin, broad-spectrum cephalosporins — minimize use |
| **Hand hygiene** | Soap and water (not alcohol-based sanitizer — does not kill C. diff spores) |
| **Isolation** | Contact precautions for confirmed or suspected C. diff |
| **Environmental cleaning** | Bleach-based disinfectant for rooms of C. diff patients |
| **PPI review** | Discontinue proton pump inhibitors when not indicated — associated with increased C. diff risk |
| **Testing** | Only test formed stool with clinical suspicion — do not test asymptomatic patients or use "test of cure" |

---

## Step 5: Document and Report HAC Events

When a potential HAC is identified:

```
HAC EVENT DOCUMENTATION

Date/Time identified: [Timestamp]
Condition: [Specific HAC type]
Present on admission: Yes / No — [Basis for determination]
Contributing factors: [Device, medication, immobility, etc.]
Immediate interventions: [What was done]
Reporting: [Infection control notified / Event report filed / 
           Risk management notified]
Root cause: [Preliminary assessment]
Prevention plan modification: [Changes to prevent recurrence]
```

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

For each patient or unit-level HAC review:

1. Are all **indwelling devices** assessed daily for continued necessity?
2. Is **POA status** documented for relevant conditions within 24 hours of admission?
3. Are **prevention bundles** (CAUTI, CLABSI, pressure injury) being followed with documented compliance?
4. Has **antibiotic stewardship** been reviewed (narrow spectrum, appropriate duration)?
5. Are **HAC events** reported through the institutional event reporting system?

---

## Quality Audit

- [ ] POA status documented for all relevant conditions within 24 hours of admission
- [ ] Foley catheter necessity assessed and documented daily
- [ ] Central line necessity assessed and documented daily
- [ ] Braden Scale completed on admission and per protocol (typically every shift)
- [ ] Pressure injury prevention interventions match Braden score level
- [ ] CAUTI prevention bundle elements documented
- [ ] CLABSI prevention bundle elements documented
- [ ] Antibiotic indications and planned duration documented for every antimicrobial
- [ ] C. difficile prevention measures in place for patients on antibiotics
- [ ] HAC events reported to infection control and institutional event system
- [ ] Device day counts documented (Foley day X, central line day X)
- [ ] Hand hygiene compliance monitored (institutional program)
- [ ] Glycemic management protocol followed (avoiding hypoglycemia < 70 mg/dL)
- [ ] Skin assessment documented with each nursing shift

---

## Guidelines

- The single most effective HAC prevention intervention is device removal — ask "Does this patient still need this device?" every day
- Never order a urinalysis or urine culture on a catheterized patient without clinical signs of infection — asymptomatic bacteriuria does not require treatment and treating it promotes C. diff and MDROs
- Document POA status meticulously — a condition documented as POA is not counted as a HAC; failure to document POA status defaults to "not present on admission" which counts against the hospital
- Pressure injury staging requires wound care or nursing documentation with measurement, location, stage, and photo when possible
- Antibiotic stewardship is C. diff prevention — review antibiotic necessity, duration, and spectrum at every daily round
- HAC data is publicly reported on CMS Hospital Compare — it affects hospital reputation, patient choice, and payer contracts
- Use a "line and device" section in every daily progress note to demonstrate ongoing assessment
- Engage nursing as the front line of HAC prevention — they perform the bundles, and physician-nurse collaboration on device removal is the most effective strategy