Critical Care Plus: Denver ICU Maintains Sedative Cost Savings

Formulary Decisions Supported by Literature

The initial 80% savings rate that Denver’s Centura-St. Anthony Central Hospital realized through standardizing a formulary for ICU sedative drugs has held firm for more than four years, according to medical director Joseph Heit, MD. Centura, which is Denver’s largest not-for-profit provider of integrated health services, is a 300-bed public facility.

The reason for standardizing the sedative drug formulary was decreasing variability, not costs, Heit says, though cost was always a determining factor when choosing between two otherwise equivalent drugs. Too much variability arose when a new drug came out that was touted as having great benefit. "New drugs were frequently adopted and used even though they were much more expensive and lacked evidence of superiority to those already available," Heit says.

Given that most drugs used for sedation in the ICU are basically narcotics or benzodiazepines—for which there are many studies that compare effectiveness—Heit felt quite confident about restricting standard usage. "There wasn’t anything in the literature that persuaded us we shouldn’t standardize and certainly patients can receive other drugs when warranted," he notes. "The literature helped us decide which narcotics or benzodiazepines work best." Heit and his colleagues picked Fentanyl as their narcotic choice.

No Basis in Literature for Choosing Versed

Heit’s team selected Valium as their benzodiazepine, despite the fact that the drug Versed was more popular than Valium at the time. Heit says he found no basis in the literature for the anecdotal belief that patients regain consciousness more quickly with Versed, which has a shorter half-life than Valium. "If you can’t come up with good logic, it makes no sense to use the more expensive drug," Heit says. "We couldn’t find any justification for relying on Versed for long-term sedation." Heit says his ICU still uses Versed for single-shot sedation, but not when the patient needs to be sedated for 24 hours or more. "Certainly, Valium is much cheaper," he says. "But if Valium were more expensive and the literature supported its benefit over Versed, we’d use it regardless of cost."

Heit’s ICU uses a modified Ramsey pain rating scale to avoid variability between what different nurses see as acceptable sedation levels. Some nurses, Heit points out, are willing to accept the patient being semi-awake and moving around a little while others want patients completely sedated. The literature, Heit says, was becoming pretty clear that using a scoring system allowed more precision. He acknowledges that it’s difficult to take a linear approach to something as variable as pain, but believes that state-of-the-art-scoring systems rather than caregivers judgement are what effective sedation in the ICU should depend upon because they work better than anything else most of the time.

"We didn’t want to limit a physician’s or nurse’s ability to vary dosages or tailor make them for an individual patient, we did want to say Give this dose if the patient shows X level of agitation,’" Heit says. "Sometimes the night nurses would over-sedate patients we wanted to wean from ventilators and we’d half to wait half a day for them to wake up enough to begin weaning."

In-House Research Supports Decision

Limiting the sedative formulary not only lowered ICU sedation costs dramatically, Heit says, but it also improved pain control. After standardizing Heit and colleagues queried ICU patients about how well they felt their pain was controlled. Heit says that not only did responses show dramatic post-standardization improvement, but patients got better faster and their subjective sense about how appropriately they were sedated rose sharply. "Before the change, about 70% of patients were satisfied with pain control," Heit says. "Now 90-95% consistently express satisfaction. Reduced risk because less time spent on ventilator. Lack of a supporting IT resource didn’t deter Heit and his team from quantifying the effects their decision created-they simply collected and compared all data by hand.

Randy Vogenberg, RPh, PhD, vice-president and pharmaceutical consulting head with Aon Consulting says Centura’s success came from aligning its drug formulary with protocols and care paths used. "You could probably do that in most hospital areas as part of process improvement activity," Vogenberg notes. "Just figure out what the areas are you want to improve and locate the best value for that kind of activity."

Vogenberg adds that many times the care paths and protocols a hospital uses are out of date or just not followed. Yet staying current is paramount to evaluating the efficacy of new drugs on the market. As an example, Vogenberg says that, typically, many hospitals have been using Heparin for thrombosis. Even though the drug is cheap, it ends up costing the hospital more money because it’s an IV infusion and the patient has to be monitored more frequently. "Looked at from cost of care, even though you may be using a less expensive, old technology drug it can cost more to use," he says.

Vogenberg’s consulting division finds the biggest opportunities for cost savings lie in the ICU. Hospitals, he says, often do a great job of assessing costs but fail to take all the actions required to harvest all the potential savings. "You need to evaluate the literature then DO what it says—take an action step," he counsels. "Are you using resources in the most appropriate fashion? A lot of formulary choices are habit. Medicine is still performed by people who practice an art, not a science and there’s a lot of existing habit that makes it hard to make changes that stick."

Contact info: Joseph Heit joeheit2000@yahoo.com or (303) 629-2106; Randy Vogenberg (781) 239-8242.