Discussion
To the best of our knowledge, this is the first report about HACs in China. In the current study, we calculated the incidence rate, mean cost and mean length of stay of HACs in three years, totally and separately. The most two common HACs in our hospital were DVT and PE, and SSI. Meanwhile, the presence of these two conditions in economic situations still needs to be attached importance. And they were followed closely by stage III and IV pressure ulcers with the highest mean cost and longest length of stay. Some situations had a relationship with the policy in China, and some improvements should have been done.
In western countries, venous thromboembolism (VTE), comprising PE and DVT, has become a major public health problem and is estimated to be the third most common cardiovascular event 11, 1211, 1211, 12. According to the research of Chen Wang, in the 105,723 identified patients with VTE, hospitalization rate increased from 3.2 to 17.5 per 100,000 populations, in-hospital mortality decreased from 4.7% to 2.1%, and the mean length of stay declined from 14 to 11 days from 2007 to 2016. In addition, the hospitalization rate of VTE was higher in elderly male patients, same with the patients with PE and DVT 13. Recently there is an increasing awareness of VTE diagnoses in physicians, along with an improvement in diagnostic techniques for the identification and more effective treatments. In China, another reason may contribute to the trends. Hospitalization itself is already recognized as an important risk factor for VTE, and inadequate prophylaxis may also contribute to the rise in incidence of VTE. We also found that patients with PE and DVT had the oldest mean age compared with other conditions, which may partly explain the reason of its occurrence. Older patients tend to be too weak to move, which is easier to form thromboembolism.
Despite nearly 2 centuries of medical progress, SSIs still played a major role in the evolution of medical care throughout history, continuing to be a leading component of nosocomial morbidity and mortality. Moreover, the management of surgical infection remains a pressing concern. However, the risk factors for SSI originate from a patient and operative factors are multitudinous14. From the perspective of patients, most of the factors can’t be controlled, while hospitals should take the responsibility to prevent SSI from the pre-operation, intra-operation, and post-operation. As to the conditions with high incidences, such as VTE/PE and SSI, medical staffs need to operate more evaluations on patients to assess the severe situation and predict the risk factor. Patients with different scores should be classified into different risk stratifications and given different treatments and prevention strategies. Though not all HAC-related patient harm events can be preventable, current efforts to create and validate specific risk scores for various clinical subgroups will likely help to reduce those events 15. But in the view of the policy of antibacterial (mentioned below), SSI may make a difference in the following years.
The mean cost of individuals with CAUTIs reduced gradually. A possible explanation may be the beginning of healthcare reform in Beijing announced by the Health Commission of Beijing. It emphasized that medical treatment and drug sales should be separated, and we would abolish medicine markups, mandate transparent drug purchase, establish medical service fee, adjust prices of 435 medical services, and promote rational use of medicines. More than 3600 hospitals and medical institutions in Beijing have launched health care reform since April 8, 2017. Meanwhile, our hospital stipulated that the management system of clinically antibacterial application must be performed seriously. This rule included that antibacterial information and technical support for clinical application must be provided to clinical medical personnel, patients must be reasonably guided to take antibiotics by medical personnel. In addition, medical personnel should also evaluate and check the use of antibiotic prescription and doctor’s advice, and report the relevant situation to the outpatient department and the medical affairs department on time. They should carry out dynamic monitoring, abnormal early antibacterial warning, and adverse events. Doctors are also required to randomly check the use of antibiotic agents in patients, and be in response to give the feedback of the unreasonable use to the relevant departments. In the setting of this loop-locked policy, the mean cost of SSI and VCAIs in 2018 received a good effect compared with those in 2017.
Manifestations of poor glycemic control ranked third. In previous research, diabetes patients have consistently higher rates of Classification of Hospital Acquired Diagnoses and longer length of stay than similar patients with complex and chronic conditions6. HACs’ different occurrences were significantly shown in diabetic patients, particularly the diabetic patients with end-organ sequelae, because they are known to be more vulnerable to infections, and other common complications, such as metabolic (primarily fluid imbalance), renal and cardiovascular complications are also danger6.
As the results show, stage III and IV pressure ulcers occupied the highest mean cost and longest mean length of stay, which imposes a substantial financial burden on the medical insurance system and patients. When expenditures are constrained, the need for high-quality health care and additional pressure ulcer specific recommendations are necessary to balance the benefit and the cost on preventing and treating, and their impact on patients, healthcare, and society17.
Since the Hospital-Acquired Condition Reduction Program (HACRP) was established, hospitals that are in the lowest-performing quartile (by HACRP score) will be penalized by reducing their payment by 1%. This program completed its goal of improving the quality of health care through financial rewards and penalties combining with two other Medicare programs (the HVBP and the HRRP)18, 19. However, there is still no policy about reducing HACs in China. So in the trend of three years, no matter in number, percentage, or economic conditions, we didn’t see a declining phenomenon, but a growing trend, such as CAUTIs, VCAIs, manifestations of poor glycemic control, and SSI. The total number and percentage are growing, though the total number of inpatients was also increased. One thing that is worth noticing is that the events of air embolism and blood incompatibility are limited to 0 in the three years. Another one is that the mean cost of individuals with CAUTIs reduced. A possible explanation may be the medical reform in the city.
It is urgent to improve our awareness of the importance of HACs and to strengthen the systematic analysis, research, and management of hospital acquisition. The correct analysis and evaluation for the occurrence of HACs, the standardization of medical behavior in accordance with evidence-based medicine guidelines, and reasonable prevention and reduction of HACs benefit to reduce the waste of medical resources and improve patient safety. Health administration departments and hospital management should raise awareness of the importance of hospital acquired problems and take practical measures to reduce its occurrence. To strengthen the management of HACs, we should consider it as an important work of hospitals and medical quality management, or a joint point to constantly improve the level of hospitals and medical treatment, to ensure patients’ safety. At present, it has become an imminent task for the hospital management in our country.