HOW OFTEN SHOULD NEVER BE? by David Torchiana, MD

There is a new term in the lexicon of quality and safety that refers to errors in medical care that are “clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (definition by the National Quality Forum). The term is never events. The idea is that certain events should never happen in hospitals and that establishing a zero tolerance for these problems and requiring public reporting will help eradicate them. Another related idea is that economic disincentives will help reduce the incidence of “botched hospitalizations,” a commonly used term for the never event concept. In a recently released, 2,000-page report, Medicare announced it will not pay hospitals for the care needed to treat patients after certain preventable medical complications. The concept is that non-payment removes the financial “reward” that currently comes with complications and will get complacent doctors and hospitals to make more of an effort to improve.

The problem is that some the events on the list really are “never events” (like wrong site or wrong patient surgery) that can and should be eliminated. But the other end of the spectrum includes conditions that may never be eliminated, although having zero as a goal is a worthy aspiration. An example of this latter category is mediastinitis, a hospital-acquired infection involving the sternum or breastbone that can occur after heart surgery. The only way there will ever be a zero incidence of mediastinitis is if heart surgery were to become obsolete or some sort of fundamental breakthrough in infection control were to occur.

There are those who may claim that mediastinitis never happens in their practice, but it is strictly a matter of time and numbers, eventually it happens in every practice. More importantly, the incentive for heart surgeons, hospitals and other caregivers to eliminate mediastinitis is already so great that it is hard to imagine that the added stimuli of public shaming and financial penalties will add much.

Mediastinitis is fortunately rare, occurring in somewhere under 1 percent of cases (perhaps as low as a few tenths of a percent). It is awful. Patients with mediastinitis sometimes die or endure lasting disability after what would otherwise have been a successful procedure. They are also miserable – weakened, in pain and troubled by the uncertainty of what lies ahead and understandably angry or depressed by their circumstances.

I think I can speak for surgeons worldwide in saying that the experience of caring for a patient with mediastinitis is, in and of itself, a powerful incentive to never have it happen again. It is truly traumatic for patients and families and stressful, abhorrent and frustrating for the surgeon. It is also financially costly for hospitals. The original hospitalization of four or five days may be followed by a readmission for infection that lasts weeks or more. The extra care required is quite costly and transforms what is normally a positive hospital margin for cardiac surgery into major red ink. The payment is hardly a reward; at my institution the average financial loss for the hospital on a mediastinitis case involving a Medicare patient is roughly $30,000.

Not surprising given its gravity, mediastinitis has received significant attention in the medical literature. There are roughly 20,000 peer reviewed publications on sternal infection and mediastinitis that have been published in the last 30 years. The risk factors and steps for prevention are well defined. Some – like timely antibiotic administration, tight blood sugar control in diabetics, meticulous surgical technique, sterility and cleanliness in the surgical environment and optimum skin preparation and wound care – are controllable.

Less controllable, but also important, are factors like the duration of surgery (simple operations are quicker, complicated ones take longer) and the condition of the patient going into surgery (emergency cases have a higher infection risk). Most significant, though, are patient factors – advanced age, obesity, diabetes, immunosuppression, severe lung disease and prior radiation – that increase the risk of mediastinitis. These can only be controlled by choosing not to treat such patients.

It is hard to imagine how not paying for the care of a patient who gets an infection, will help to reduce the problem of mediastinitis for others. No one wants any of the never events to happen, but some of them will never be eliminated. Not paying for needed care has no added incentive value. It merely shifts costs elsewhere and is empty grandstanding.

David Torchiana, MD
CEO of the Massachusetts General Physicians Organization