Decreasing the Costs of Critical Care
By Leslie A. Hoffman, PhD, RN
Today, survival of a health care system is increasingly dependent on the ability to identify ways to deliver high quality care at a lower cost. To achieve this goal, critical care practitioners need to monitor outcomes and identify creative ways to reduce costs. The following synopsis highlights recent studies and commentaries that suggest ways of accomplishing the goal using computer monitoring, e-mail, and expanded roles.
More Cost-Effective Use of Antibiotics
Physician decisions control 70-80% of all health care dollars spent, and strategies to influence or control physician decision-making therefore have a prominent place in cost-reduction plans.1 These strategies include education, peer review, administrative directives (suggestions), financial incentives, case management, and national guidelines.
Pestok et al tested a different approach—use of an antibiotic management program that used local clinician-derived consensus guidelines imbedded in computer-assisted decision support programs.2 The program included prescribing guidelines for prophylactic, empiric, and therapeutic use of antibiotics. During the seven-year study period (1988-1994), 63,759 patients received antibiotics.
Analysis of daily antibiotic doses showed that overall antibiotic use declined by 22.8%. Antibiotic costs per treated patient (adjusted for inflation) decreased, from $123/patient in 1988 to $52/patient in 1994. The percentage of patients having surgery who received appropriately timed preoperative antibiotics increased from 40% in 1988 to 99.1% in 1994. Adverse drug events decreased by 30%. No adverse outcomes were noted. Antibiotic resistance patterns were stable, length of stay remained the same, and mortality decreased from 3.65% (1988) to 2.65% (1994). Thus, the program improved both the quality and cost of care.
Prompt administration of appropriate antimicrobial agents is essential in the treatment of bacteremia. To improve treatment of such patients, Herchline and Gros evaluated a system in which all positive blood cultures were reported via e-mail to an infectious disease specialist as soon as growth was noted.3 This individual reviewed all Gram stains, clinical data, and antibiotic information on these patients. Over an 18-month period, 199 blood cultures were positive and nine patients were on inadequate therapy, as judged by final organism susceptibilities. Changes in empiric therapy were recommended in five cases. Each change resulted in improved coverage, as judged by the final identification and susceptibilities. The authors estimate the program cost one additional hour of consultant time per week. Although implemented using an infectious disease specialist, the authors note that many review activities could be carried out by a pharmacist or infection control practitioner.
Protocol-Driven Respiratory Care in the ICU
Each day that mechanical ventilation continues when not required exposes the patient to additional risk of complications and unnecessarily increases costs. Although it is assumed that patients are weaned from mechanical ventilation as soon as possible, there is evidence that this may not be occurring. Ely et al demonstrated that patients were weaned from mechanical ventilation sooner if they were assessed daily by nurses and respiratory therapists to identify patients capable of breathing spontaneously.4 The three-part intervention consisted of: 1) daily assessment; 2) a two-hour trial of spontaneous breathing in patients judged able to breathe spontaneously; and 3) notifying the physician if the patient successfully completed the trial. Most monitoring was done as part of standard patient care, thus personnel costs were minimal. Although patients randomized to the intervention had more severe disease, they received mechanical ventilation for 4.5 days compared to six days for the control group. Thus, this simple intervention shortened the duration of mechanical ventilation by about two days. ICU costs were significantly less. Hospital costs also decreased but not significantly.
Similar findings were reported by Wood et al who tested a respiratory therapist-directed protocol for weaning cardiac surgery patients from mechanical ventilation.5 No complications were associated with therapist-driven weaning and patients weaned by the therapist-driven protocol had a significantly shorter median ventilation time following cardiac surgery.
Kirby and Durbin tested an intervention designed to prevent readmission of patients to the ICU.6 Respiratory care was delivered by a dedicated team of respiratory therapists who were notified of all impending ICU discharges and saw these patients in a timely fashion, usually prior to ICU discharge. Transferred patients with respiratory problems were aggressively treated by the team using algorithms. Pre- and post-program comparisons did not show a decrease in overall ICU re-admission rate (4.7% vs 4.8%) or the percentage of patients re-admitted for respiratory failure (43% vs 54%). However, there was a significant decline in mortality for the intervention group compared to the control group for all readmitted patients (12% vs 41%) and patients readmitted for respiratory failure (19% vs 47%)
Emergence of the "Hospitalist"
Managed care is bringing about many changes in the ways hospital-based care is provided. In the outpatient setting, the premium on efficiency requires that the physician provide care for large numbers of patients and be available to see them promptly.7 The efficiency of outpatient care is markedly impacted by time required to travel to see hospitalized patients, whether across the street, across town, or many miles and hours away if the practice is located in a rural setting. There are similar pressures for efficiency in the hospital, where there is need to respond quickly to change in patient condition and use resources as parsimoniously as possible.
For this reason, Wachter and Goldman anticipate growth of a new type of specialist, termed a "hospitalist," who specializes in in-patient care.7 Hospitalists are being used in California and other areas where managed care is predominant. This approach is modeled from the "closed ICU", in which patients requiring ICU admission are transferred to the care of a critical care specialist or team. Care in a closed ICU has been shown to be more cost effective than care in an "open ICU", in which critical care specialists are available to provide consultation but do not direct care.8 Several models of "hospitalist" care are now being used. These include a dedicated admitting physician who assumes week-long duty, a full-time hospitalist who assists admitting physicians, or a full-time hospitalist assigned to manage all inpatient care. Anecdotal reports suggest that each "hospitalist" model has decreased length of stay, hospital costs, and specialty consultation.7 Potentially, this role could also be assumed, at least in part, by an acute care nurse practitioner.
Better Care at the End-of-Life
Campbell and Frank recently reported their 10-year experience with a service called the Comprehensive Support Team (CST), which has cared for more than 1400 dying patients and their families.9 At these authors’ institution, a Level I emergency trauma hospital, more than 30% of the beds are dedicated to critical care. Patients not expected to survive hospitalization are referred to the CST, led by Campbell, an advance practice nurse with prescriptive privileges. If the patient is deemed appropriate for CST care, a plan is developed with the patient (if possible) and family. Campbell rounds with team physicians and manages care, until the patient’s death or discharge (usually to a hospice). Patients are managed according to protocols, with attention given to comfort, especially adequate pain control. Care includes management of terminal weaning. Since CST introduction, length of stay declined from 13 to four days. In 1995, costs savings from bed use alone were substantial.
Each of these studies underscores the key role monitoring and creative change can plan in reducing health care costs. Nurses and respiratory care practitioners working in expanded roles are a key resource and these efforts should be more broadly tested to document ability to reduce health care costs. Adding to cost efficiency, most of the changes introduced were integrated into daily care, minimizing the cost of extra personnel.
1. Volpp KG, Schwartz JS. JAMA 1994;271:1370-1372.
2. Pestotnik SL, et al. Ann Intern Med 1996;124:884-890.
3. Herchline T, Gros S. Infec Control Hosp Epidemiol 1997;18:38-41.
4. Ely EW, et al. N Engl J Med 335:1864-1869.
5. Wood G, et al. Respir Care 1995;40:219-224.
6. Kirby EG, Durbin CG. Respir Care 1996;41:903-907.
7. Wachter RM, Goldman L. N Engl J Med 1996;335:514-516.
8. Carson SS, et al. JAMA 1996;276:322-328.
9. Campbell ML, Frank RR. Crit Care Med 1996;25:197-200.