Want a better-run ICU? Screen patients, doctors

Tighten drug formularies and discharge planning

An expensive, dangerous environment: That’s how Thomas Rainey, MD, describes the typical intensive care unit. Rainey, president of CriticalMed, a health care consulting firm based in Potomac, MD, says many ICUs are chaotic places where patients get anything but intensive care.

Instead, poorly managed ICUs operate like financial black holes, sucking money and resources from nearly every other department in the hospital.

And the longer patients stay in the ICU, the more risk to their health. Stubborn bacterial and fungal infections are common in the ICU — infections that require treatment with expensive antibiotics. Thus the pharmacy gets pulled into the hole. The nursing staff can’t escape the gravitational pull, either, as ICU patients generally require more care.

Up to one-third of patients don’t belong

But some ICU patients don’t need the additional care. In fact, Rainey says up to a third of patients in the ICU don’t belong there. Some may be stable enough for transfer to the floor, but there aren’t any beds. But others never belonged in the ICU in the first place — and for those admissions, blame the doctors, Rainey says. No group has more power over the financial health of the ICU than the clinicians, he says — for one simple reason: "They have a say with minimal exertion of the rules on whether a patient stays or goes from the ICU."

Patients who stay in the unit incur astronomically high costs: ICUs care for less than 10% of patients on average, but they can devour a third of a hospital’s operating budget. The high cost starts with the ICU bed itself, then expands to encompass sophisticated monitoring devices, sterile tubing, drugs, and extra nursing hours.

Cutting unnecessary days in the ICU

No wonder, then, that hospitals around the country are looking to get patients out of the ICU as fast as possible. One way is to offer alternatives to the unit. Muhlenberg Regional Medical Center in Plainfield, NJ, found that one reason physicians were more comfortable admitting seriously ill patients to the ICU rather than to a floor bed was because the ICU had a high-tech feel.

But some of those patients didn’t need constant monitoring. So to curtail unwarranted ICU admissions, the hospital created a Flex-Up intermediate care unit — an area that provides care for the acutely ill who are expected to recover. These patients might include those with chest pains (but few other symptoms of a myocardial infarction) or post-surgical patients with special monitoring needs.

Overlook Hospital in Summit, NJ, took the same tack. With a goal of cutting low-risk admissions to the ICU by 50%, the hospital developed an intermediate care unit for patients needing less direct nursing care. Within a few months, low-risk ICU admissions dropped by 57%, and the average length of stay in the ICU was cut by nearly a day. With fewer nursing hours needed, the hospital saved $50,000 in nursing salaries.

Rainey suggests several other ways hospitals can cut unnecessary days in the unit. First, hospitals should actively follow a "living" admission and discharge document. Rainey says too often these rules sit in a corner and gather dust, allowing physicians to ignore the rules. "The rules for triage are poorly enforced," he says. "There’s no penalty for doctors who insist on keeping a patient in the ICU over a weekend."

Why do doctors ignore admission and discharge rules? Rainey says it often boils down to money — their own, that is. Doctors may fear their patients are too sick to go to the floor and that a sudden turn for the worse may affect their malpractice insurance rates. Or there may be more nefarious motives, he suggests: Doctors may have a direct financial interest in keeping a patient in the ICU because they can bill more. In fee-for-service systems, for example, doctors bill more if a patient stays on a ventilator, Rainey says.

Rainey also advocates hospitals adopting a "culture of advance planning" when it comes to admitting patients to the ICU. In other words, implement a plan to discharge patients as they are admitted to the unit. He suggests a cooperative effort on each shift to identify the most likely candidates for discharge and to keep track of available beds on the floor. Don’t wait until the last minute to find an empty mattress, he adds.

ICU pharmacist helps control costs

While drugs make up only about 10% to 20% of ICU costs, Rainey says there’s a major problem with the overuse of pharmaceuticals, especially sedatives, neuromuscular blockers, and antibiotics. Rainey says physicians sometimes resist positioning a pharmacist in the ICU, but that having a drug expert on hand can help unit personnel sort through the huge and often unusual arsenal of products used for critically ill patients.

It’s also important to address medical complications before they happen. Rainey complains that ICU personnel have been conditioned to operate in a short-term crisis mode and thus don’t plan well for slowly developing complications such as infections, pressure sores, or thromboembolisms. Therefore, he says, beware of ICUs that take great pride in cardiac resuscitation rates. They may have had a little too much practice.

And finally, there’s the issue of medical tests. "We need to establish a culture that’s asking, ‘Why are you ordering the test?’ instead of, ‘Why not?’" Rainey says. Too often, medical tests are bundled or are ordered via check-off forms, he says. Unbundle the tests, dump the check-off forms, and while you’re streamlining, eliminate automatic daily EKGs and chest X-rays, he says.