This image depicts Centers for Disease Control (CDC) microbiologist Valerie Albrecht, as she was holding up for observation, two Petri dish culture plates that had been inoculated with methicillin-resistant Staphylococcus aureus (MRSA) bacteria.
This image depicts Centers for Disease Control (CDC) microbiologist Valerie Albrecht, as she was holding up for observation, two Petri dish culture plates that had been inoculated with methicillin-resistant Staphylococcus aureus (MRSA) bacteria. Credit: Courtesy / CDC

About 15 percent of Texas hospitals – 37 out of 245 – will lose part of their Medicare payments in 2018 as a penalty for having relatively high numbers of patients who acquired preventable injuries and infections while hospitalized.

In San Antonio, CHRISTUS Santa Rosa, Southwest General, and University Health System are among the 751 hospitals nationwide that will lose 1 percent of their Medicare reimbursements in this fiscal year.

The penalties are part of the Centers for Medicare and Medicaid Services’ (CMS) program to reduce injuries and infections acquired in hospitals. The program was created under the Affordable Care Act and designed as a financial incentive for hospitals to take measures to prevent infections and other complications in hospitalized patients.

The program measures rates of infections, including those related to certain catheters and intravenous lines, certain surgeries, and antibiotic-resistant bacteria infections. Medicare also takes into account the frequency of 10 types of in-hospital injuries, including hip fractures, bed sores, sepsis, blood clots, and post-surgical wound ruptures. These potentially avoidable events are known as hospital-acquired conditions, or HACs.

Methodist Hospital Stone Oak and Nix Healthcare System were penalized in fiscal year 2017, which ended in 2016, but improved their rate of patient injuries enough to avoid being ranked in the lowest-performing quarter of hospitals this year.

Andrew Morales, marketing manager with Nix, said that one of the hospital’s notable successes was completely eliminating central line-associated bloodstream infections, which CMS reviews when determining financial penalties.

“This was accomplished, in part, by implementing a new protocol and providing physicians, nurses, and other staff with additional training in the use of less invasive catheters for intravenous therapy,” said Morales, who called reducing HACs “a major clinical focus” for Nix.

Morales said that reducing hospital-acquired infections at Nix has been driven by advances in technology and accomplished by providing staff with up-to-date training and education.

Such efforts by hospitals to combat hospital-acquired conditions seem to be working. Nationally, hospital-acquired conditions declined by 21 percent between 2010 and 2015, according to the federal Agency for Healthcare Research and Quality (AHRQ), which analyzes data and policies for the U.S. Department of Health and Human Services. In total, hospital patients experienced more than 3 million fewer hospital-acquired conditions during that period, with the biggest reductions seen in post-surgical blood clots, catheter infections, and bad reactions to medicines.

Still, hospital harm remains a threat. Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals, according to the Centers for Disease Control and Prevention. At least 23,000 people die each year as a direct result of these infections.

One resistant bacteria that Medicare included in its formula for determining financial penalties for hospitals is methicillin-resistant Staphylococcus aureus, or MRSA, which can cause bloodstream and skin infections and pneumonia. People with MRSA often will show no signs of the disease, then unknowingly bring the germ into a hospital where it is spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. MRSA may be especially dangerous for older or sick patients whose immune system is too weak to fight off the infection.

Hospitals have had some success in reducing MRSA infections, which dropped by 13 percent between 2011 and 2014, according to the CDC. AHRQ estimates there were 6,300 cases in hospitals in 2015.

For hospitals in San Antonio, MRSA scores are highest at University Health System, followed by Southwest General Hospital, with CHRISTUS Santa Rosa close behind.

Katy Kiser, public relations manager with CHRISTUS Santa Rosa told the Rivard Report that its facilities emphasize hand washing to combat the spread of infection. Hand washing, while a seemingly small step in infection prevention, is considered “the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections” by the World Health Organization.

CHRISTUS Santa Rosa monitors hand hygiene by measuring hand sanitizer and soap use, conducting surveys, and direct observation. Kiser said that they have achieved “high levels of hand hygiene compliance.”

“Since 2015 we have decreased our infection rates by more than 40 percent,” she said.

Another bacterial infection rate measured by is Clostridium difficile, known as C. diff, a germ that can multiply in the gut and colon when patients take some antibiotics to kill off other germs. It can also spread through contaminated surfaces or hands.

While it can be treated by antibiotics, C. diff can also become so serious that some patients need to have part of their intestines surgically removed, and may be deadly for elderly or medically vulnerable patients. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes.

C. diff was estimated to cause almost half a million infections in the United States in 2011, and 29,000 died within 30 days of the initial diagnosis, according to the CDC.

In San Antonio, University Health System has the highest C. diff scores, followed by Southwest General and CHRISTUS Santa Rosa.

Dr. Bryan Alsip, University Health System’s executive vice president and chief medical officer, stated that the hospital has “demonstrated improvements” in hospital-acquired infection rates, and have “employed infection control and prevention teams to work with physicians, nurses, and other providers to improve protocols, train staff, and track outcomes.”

University Health System also utilizes the high-tech Xenex disinfection system, which use a powerful xenon ultraviolet light to kill a wide range of infectious organisms in patient rooms, critical care areas, and operating suites.

Kiser said that CHRISTUS Santa Rosa has implemented a CDC-recommended program to train staff to ensure that antibiotics are being used appropriately in order to reduce the spread of infections caused by drug-resistant bacteria.

The CDC reports that bloodstream infections associated with central lines result in thousands of deaths each year and billions of dollars in added cost to the U.S. health care system, but these infections are preventable. Health care providers must follow a strict protocol when inserting the line to make sure the line remains sterile and infection does not occur.

University Health System, which has the lowest number among San Antonio hospitals of central line-associated bloodstream infections for the past fiscal year, has recently implemented a system of tracking infections in near-real time that will allow it to “more easily monitor [infections] down to the unit level and to ensure accountability,” according to Alsip.

Southwest General Hospital has the highest rate of such infections, more than double that of CHRISTUS Santa Rosa and University Health System.

Representatives from Southwest General Hospital did not respond to multiple requests for comment from the Rivard Report.

Nix Hospital reduced its numbers of catheter-associated urinary tract infections by implementing new protocols that emphasize the earlier removal of catheters from patients to reduce the risk of infection, according to Morales.

University Health System leads San Antonio in catheter infection numbers, followed by Southwest General Hospital and CHRISTUS Santa Rosa.

While the government did not release the dollar amount of the penalties, they will exceed a million dollars for many larger hospitals. In fiscal year 2017, hospitals lost around $430 million in Medicare payments due to high hospital-acquired infection rates, according to an estimate from the Association of American Medical Colleges.

Roseanna Garza reports on health and bioscience for the San Antonio Report.