What are the recommendations for applying HHS (U.S. Department of Health and Human Services) criteria to prevent hospital-acquired conditions in an adult patient with a complex medical history?

HHS Criteria for Hospital-Acquired Conditions

Critical Clarification

The term "HHS criteria" in your question likely refers to the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP), which identifies specific preventable hospital-acquired conditions (HACs) for tracking and non-payment purposes. 1

Understanding Hospital-Acquired Conditions

The CMS defines HACs as conditions that are:

• High cost or high volume (or both)
• Assigned a higher-paying diagnosis-related group (DRG) when present as a secondary diagnosis
• Reasonably preventable when evidence-based guidelines are employed 1

As of October 1,2008, CMS ceased paying hospitals for targeted preventable HACs that develop during a Medicare patient's hospital stay and were not present at admission. 1

Key Hospital-Acquired Conditions Targeted by CMS

The most common preventable HACs include:

Infections (Most Prevalent Category)

• Postoperative wound infections (44.4% of all HACs) 2
• Catheter-related urinary tract infections (15.9% of all HACs) 2
• Central venous catheter-associated infections (7.9% of all HACs) 2
• Hospital-acquired pneumonia (6.3% of all HACs, occurring ≥48 hours after admission) 3, 2

Other Preventable Conditions

• Abscess formation 2
• Oral candidiasis 2
• Pressure ulcers
• Falls and trauma
• Surgical site infections 2

Clinical Implications for Complex Medical Patients

Hospital-Acquired Pneumonia Risk Stratification

Patients with complex medical histories require immediate hospital admission when presenting with lower respiratory tract infections if they exhibit any of the following criteria:

Vital Sign Abnormalities:

• Temperature <35°C or ≥40°C
• Heart rate ≥125 beats/min
• Respiratory rate ≥30 breaths/min
• Blood pressure <90/60 mmHg
• Cyanosis 3, 4, 5

Laboratory Abnormalities:

• Leukopenia (<4,000 WBC/mL) or severe leukocytosis (>20,000 WBC/mL)
• Anemia (hemoglobin <9 g/100 mL)
• Renal impairment (serum urea >7 mM or creatinine >1.2 mg/dL)
• PaO₂ <60 mmHg or PaCO₂ >50 mmHg on room air
• Acidosis (pH <7.3)
• Coagulation abnormalities suggesting disseminated intravascular coagulation 3, 5, 6

Radiographic Findings:

• Multilobar involvement
• Pleural effusion
• Cavitation 3, 4

High-Risk Comorbidities Requiring Lower Admission Threshold

Patients with the following conditions have increased risk of HAP development and complications:

• Age >65 years 3, 5
• Chronic obstructive pulmonary disease 3
• Diabetes mellitus 3, 5
• Congestive heart failure 3, 5
• Chronic liver disease 3, 5
• Chronic renal failure 3, 5
• Malignancy 3, 5
• Neurological diseases (including cerebrovascular disease) 3
• Immunocompromised status 5
• Recent hospitalization within the past year 3

Prevention Strategies for HAPs

Hospital-Acquired Pneumonia Prevention

For mechanically ventilated patients (highest risk group):

• Mechanical ventilation >48 hours is the single strongest risk factor for HAP 7
• ICU residence and duration of stay directly correlate with HAP risk 7

Diagnostic sampling before antibiotic changes:

• Lower respiratory tract cultures should be obtained from all patients with suspected HAP before antibiotic modifications 3
• Sterile cultures in the absence of recent antibiotic changes (within 72 hours) strongly suggest pneumonia is not present 3

Catheter-Related Infection Prevention

For urinary catheter management:

• Remove catheters as soon as clinically appropriate 2
• Most catheter-related urinary infections occur in emergency patients 2

For central venous catheters:

• Use strict sterile technique during insertion 2
• Daily assessment of continued need 2

Surgical Site Infection Prevention

Critical timing consideration:

• Most postoperative wound infections are diagnosed after hospital discharge 2
• Implement post-discharge surveillance protocols 2

Mortality and Resource Utilization Data

Hospital-acquired severe sepsis (including HAP-related sepsis) demonstrates significantly worse outcomes compared to community-acquired infections:

• Hospital-acquired severe sepsis mortality: 19.2%
• Healthcare-associated severe sepsis mortality: 12.8%
• Community-acquired severe sepsis mortality: 8.6% 8

Resource utilization for hospital-acquired severe sepsis:

• Median hospital length of stay: 17 days
• Median ICU length of stay: 8 days
• Median hospital costs: $38,369 8

Important Caveats

Approximately 76.2% of HACs are judged as probably preventable, with only 11.1% considered definitively preventable. 2 This suggests that while evidence-based guidelines reduce HAC rates, complete elimination is unrealistic given patient complexity.

HAC rates may paradoxically be higher at high-quality academic centers due to more complete documentation, sicker patient populations, and longer lengths of stay rather than inferior care quality. 9 Large academic centers, ACS Level I trauma centers, and hospitals with >600 beds are over-represented in high HAC rate quartiles. 9