Denver hospital reduces sedation drug costs by 80%
Drug choices, dosing rules boost effectiveness
Effective management of sedation agents in the ICU makes good medical sense. But ICU managers also face keen cost-control pressures. That’s why the news that a Colorado hospital’s ICU staff got not long ago came as a welcome surprise.
Clinicians at Centura-St. Anthony Central Hospital in Denver were stunned by the discovery that their sedation drug costs in the medical ICU had dropped by 80% without any adverse reaction in patients.
According to a report issued last year, the critical care team at the 498-bed hospital began in the spring of 1996 to streamline the use of an arsenal of analgesics and benzodiazepines commonly used to sedate ventilator-dependent and other critically ill patients.
The goal was to study the optimum effectiveness of an array of drugs most favored by physicians in hopes of narrowing the list to the most effective ones.
"We wanted to standardize their use to get an accurate measure of how well they worked on patients. It’s hard to know which medications are most effective when there are so many different regimens in use," says Joseph Heit, MD, director of the medical ICU at Centura.
The study’s objective wasn’t cost savings but better patient outcomes. But the unexpected 80% drop in costs per patient per day over a 12-month period couldn’t be overlooked. "It came as something of a surprise," Heit concludes.
Following the introduction of the unit’s new sedation protocol, the average sedation cost per patient/per day dropped to as low as $6.23 from an average of $49 per day. The average amount fell to $9.80, according to figures reported by the hospital.
Formularies limit drug choices
In critical care, setting up an effective sedation protocol can be elusive. Although the choices of drugs are relatively limited to hypnotic propofols and benzodiazepines, the variety of individual sedatives that fall into these two categories and their dosages on patients can vary broadly from patient to patient.
Individual clinicians tend to order sedation agents on the basis of what works best in their opinion, says Heit. And nurses use their own interpretation of pain and anxiety when adjusting dosages. The dosage can vary substantially depending on the patient’s condition at a given time and the attending nurse’s own perceptions of pain and discomfort.
Consequently, the wide variability in dosing and the specific sedation agents used make managing sedation in the ICU difficult, says researcher Anne Pohlman, RN, MSN, CCRN, a clinical nurse specialist in the adult ICU at the University of Chicago Hospitals. "There is no perfect drug."
But that shouldn’t deter nurses, adds Pohlman, who spoke at last month’s National Teaching Institute meeting in New Orleans, sponsored by the American Association of Critical Care Nurses.
In reality, many of the decisions regarding drug choice and cost already have been made by the hospital in the form of drug formularies, which indirectly dictate which drugs are approved for use.
In most cases, these will be the cheaper, more generic drugs that also may be shorter lasting. For this reason, ICU managers and physicians need to be keenly aware of the myriad effects these hospital drug-buying decisions will ultimately have on patient outcomes, lengths of stay, and the ICU’s cost structure. "It’s not enough to say that the cheaper drug will be less effective. Nurses need to work with what they have and reassess each patient continuously," Pohlman advises. "A cheaper, shorter-lasting titratable drug may work out fine for some patients, but may be driving up your costs with others."
Studies have shown that certain sedation agents can prolong the dependence of some patients on mechanical ventilators and defeat weaning strategies.
One such study found that a group of patients on mechanical ventilation who received continuous intravenous sedation stayed on the vent at least 30% longer in a two-week period than patients who were not on continuous IV sedation.1
IV sedation tends to prolong vent dependence
These same IV-sedated patients, according to the study, also "had significantly longer lengths of intensive care and hospitalization, more acquired organ system derangements, and greater incidence of reintubation."
Motivated by similar concerns, Centura clinicians decided to evaluate their existing sedation practices, says Heit. The hospital’s effort actually was part of a broader set of goals that included: 1) getting more consistency in the timing and delivery of ancillary services such as X-rays and enteral feeding to ICU patients; 2) improving the management of common conditions such as diabetic ketoacidosis in the ICU; and 3) building a multidisciplinary team to do patient rounds.
The ICU staff looked at the types of drugs most often used at the hospital for sedating critically ill patients. This list included Haldol, Paradol, Verced, and Deprivan. After several discussions with attending physicians and bedside nurses, the investigators decided to narrow the list to two drugs: Fentanyl and Valium. A concurrent search of the medical literature supported their selection, Heit says.
Heit acknowledged that some clinicians doubted the choice of Valium because it tended to keep patients asleep longer than other drugs, and this would make ventilator weaning all the more difficult. But the team chose Valium based on research findings, Heit recalls, which indicated that Valium worked faster than another highly favored drug, Verced.
Fortunately, the drug-screening process was helped by the amount of information available in the literature on the benzodiazepine class of drugs, especially regarding the drugs’ half-life and their effect on patients with multi-organ system failure. The research team didn’t account for differences in effectiveness between titratable sedation and those administered by nurses as needed.
The search helped in narrowing the choices down to Fentanyl based on two key traits: the ability of the staff to control the duration of the drug’s effectiveness and its relative low cost.
However, the research team didn’t impose any strictures on individual physicians or nurses. Clinicians were allowed to use whichever medication they considered best. "We were not trying to assert that any one drug was better than another. Physicians were free to make their own choices," Heit says.
But clinicians who chose to use drugs other than Fentanyl or Valium had to report the fact to the clinical team for documentation.
The team documented the use of the two drugs each day for several weeks to determine the effects of standardization. To further close the variability gap, the staff agreed to use a modified Ramsey pain-rating scale, a standard tool that attempts to quantify pain levels in patients by assigning numerical score pain indicators based on physical parameters such as facial expressions, vital signs, and motor responses.
Unlike other standard rating tools, the Ramsay scale was useful, Heit says, because it was sufficiently sensitive to account for critically ill patients’ multiple-organ dysfunction and nurses’ breadth of pain interpretation.
As a rule, many nurses tended to over-medicate patients for pain, and although the rating scale didn’t provide absolute uniformity in dosage volumes or occurrences, it helped to significantly narrow the margin in which patients were medicated and when, Heit adds.
After tracking results of these changes, Heit and his team discovered that the pace of ventilator weaning for some patients improved and patient complaints of pain (reported retrospectively through interviews with family members and satisfaction questionnaires) had dropped significantly.
The rates of change in both categories were difficult to quantify exactly because additional vent-weaning strategies were simultaneously being used with the sedation protocol. They included shorter intervals of nurse-patient monitoring and specific changes in nutritional support.
But the patient satisfaction questionnaires indicated that patients’ episodes of pain were being effectively addressed up to 98% of the time. Prior to the sedation protocol, patients reported their pain episodes were controlled only about 70% of the time, the hospital reported.
Yet, the drop in sedation cost was the most surprising outcome, Heit says. Prior to the protocol’s adoption, average sedation costs were quite different per patient. (See chart on p. 77.)
The average cost was obtained by dividing the number of patient days per month into the unit’s sedation cost (per pharmacy) each month.
Closing the variability gap in dosings and drugs certainly helped. But "a significant factor that drove down these costs was the fact that the drugs ultimately selected were cheaper," Heit says. Yet, this doesn’t necessarily mean other hospitals will arrive at the same results.
Managing sedation drugs remains a tricky affair, Pohlman cautions. Sedation management should always be patient-focused, not cost-based. "Are some sedation drugs more expensive than others? You’ll have to factor in how well it works on your patient. That’s the bottom line," Pohlman adds.
Reference
1. Kollef MH, Levy NT, Ahrens TS, et al. The use of continuous IC sedation is associated with prolongation of mechanical ventilation. Chest 1998; 114:541-547.
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