Pharmacy improvements can lower costs, improve care for ICU patients

Some solutions mean looking beyond the next crisis

When Muhlenberg Hospital in Plainfield, NJ, sought to reduce the number of intensive care unit patients suffering expensive bouts of diarrhea, staff found that improving care also reduced costs.

Diarrhea? Expensive? You bet. Each time an ICU patient suffers a loose stool, the costs mount — from the gloves and gowns staff wear to clean the patient, to intravenous hydration, to the tests for C. difficile. Not to mention the time it all takes. The hospital calculated that a single day’s worth of diarrhea in one patient involved eight hours of additional caregiver time.

One reason hospital patients get diarrhea is the use of antibiotics. But diarrhea in ICU patients often has other causes. Two common culprits: Pre-packaged sorbitol solutions and liquid fats. Sorbitol, an intensely concentrated sugar, causes osmotic diarrhea — even when small amounts are ingested. Patients unable to swallow solid dosage forms are sometimes dosed with sorbitol solutions of drugs. And the lipid solutions given as part of hyperalimentation therapy sometimes act like lubricating laxatives.

Reducing the use of sorbitol-containing solutions was paramount to the success of the anti-diarrhea campaign, as was switching patients over as quickly as possible to solid food high in fiber. These steps led to a dramatic drop in diarrhea, to the point where the hospital’s ICU staff couldn’t remember the last time a unit patient had a "truly severe" case.

A number of risk factors can contribute to gastric bleeding in ICU patients, but not everyone in the unit is equally susceptible. Still, many ICU patients are automatically treated with expensive intravenous H2 blockers. Peter Dodek, MD, director of the intensive care unit at St. Paul’s Hospital in Vancouver, BC, developed a flowchart to minimize wasteful use of IV ranitidine.

Unless patients suffer from a specific symptom on admission to the ICU, no stress ulcer prophylaxis is given. The flowchart also diverts symptomatic patients with gastric access into two groups: those who can get by on oral sucralfate, which is a cheaper drug, and those who need IV ranitidine. Once the program was put into place, the average cost per day of stress ulcer prophylaxis dropped from about $2.50 (Canadian) to about $1.31 (Canadian).

Dramatic savings with use of protocols

Phoebe Putney Hospital in Albany, GA, had one main objective in its ICU: cutting the number of days patients spent on ventilators. What hospital officials didn’t realize was how dramatically pharmacy costs would be reduced in the process. "Some doctors were using very large doses and many different sedatives and neuromuscular blocking agents that could potentially keep patients on the ventilator longer," says Laura Young, MSN, vice president of patient care services.

Young says the hospital developed voluntary sedative and neuromuscular blocker protocols, then studied the results, using patients of physicians who failed to follow the protocols as a control group. The results were stunning. In patients who were equally sick, according to mortality prediction scores, pharmacy charges averaged about $4,000 in patients who were in the protocols, and four times that much in those who weren’t. "We were just amazed," Young says.

Because blood sugar and electrolyte levels play a role in vent-weaning, the hospital developed protocols to deal with insulin, potassium, and magnesium as well. Overall, patient outcomes were significantly better in the group treated by the protocols: These patients stayed in the hospital and the ICU only half as long as non-protocol patients and were weaned off the ventilator twice as fast. Plus, the mortality rate was halved.

The results were so significant that the hospital’s department of medicine plans to consider whether to make the protocols "opt out" vs. "opt in" — that is, patients would be automatically enrolled in the protocols unless the phy-sician opted out of the treatment. "We believe this is the best practice," Young says. "Given we have better outcomes clinically and financially what’s the reason not to [follow the protocols]?"