Cost savings run deep in new bed-use program
Collaborative project nets six-figure savings
Tighter surveillance of how rotational beds are used in ICUs and acute care floors saved two Texas hospitals more than $500,000 in a year with no reduction in personnel.
At Baylor Medical Center in Dallas, for instance, an ICU nurse in each critical care unit has become a gatekeeper, guarding the use of the expensive rotational beds to ensure they are ordered only for patients who truly need them.
Baylor is one of 12 hospitals that participated in a VHA Southwest Inc. program that examined the common practice of using rotational beds for preventing pressure sores. That is an area that can potentially produce large savings since about 1.7 million patients a year develop pressure ulcers, adding an estimated $8.5 billion to the cost of hospitalization. The cost of treating a single case of pressure sores can range from $10,000 to $40,000. Estimates are that pressure ulcers develop in about one-third of ICU patients and have a 60% prevalence in quadriplegics.
When the VHA team members began looking at their own programs, they saw one particularly expensive and unnecessary problem: Too much emphasis was being placed on using the rotational beds.
Part of the problem was that staff were relying on information from the bed companies, rather than using a protocol developed by wound care specialists, says Jeannie Ebnet, RN, CETN, an enterostomal therapist (ET) at Trinity Mother Frances Health Systems in Tyler, TX, and a member of a VHA team that engineered the changes.
Rotational beds tilt patients by using a flow of air within the pillow cushions. "They are actually designed to be used with patients who have pulmonary complications, rather than pressure sores," says Sarann Nolen, RN, CETN, an ET at the Baylor University Medical Center in Dallas, and a member of the VHA team. "But sales reps promoted them as such, and many nurses perceived that a patient on a rotational bed would not need turning as often."
Wound care protocols established
The first step was for the VHA to develop protocols to standardize wound care, and the team started by examining data from McFaul & Lyons, a Trenton, NJ-based consulting firm that had conducted a comparative analysis on pressure sore expenditures for the 12 organizations.
Baylor assembled an internal continuous quality improvement team to monitor rotational bed use. The team comprised ICU nurses, a director of the respiratory department, a respiratory technician, ET nurses, a nutritionist, nursing assistants, and floor nurses, as well as a representative from nursing education. "For a month, anytime a bed was ordered, we evaluated who ordered it and why," Nolen explains. "We found that nurses perceived there was a skin protective value with rotational therapy." Yet, a subsequent literature review did not support this premise promulgated by the bed companies, she notes.
"The monitoring also revealed that [trauma] patients were staying on the beds for as long as three weeks, even though the vendors’ literature stated that maximum efficiency was achieved in five days," Nolen says.
The end result of the process was protocols all hospitals could follow to help determine when a rotational bed was appropriate. (For key elements of the protocol, see story, below.)
After implementing the changes, Baylor reduced its 1996 costs for rotational bed rentals by $352,240 a 70% reduction with no increase in skin breakdown, says Nolen. Trinity Mother Frances reduced its rotational bed costs by $200,000.
A key to making the improvements stick has been the use of gatekeepers to screen bed orders, ensuring that only a medical director of a critical care unit or a trauma surgeon can order them. "Previously, anyone could order them," notes Ebnet. "What we found was not only that more nurses were ordering them than physicians, but also nurses weren’t using them appropriately. They were under the impression that they didn’t have to turn the patients as often. I really think it was a case of a sales job from the reps."
Use a supertrainer
To make sure nurses received the correct information about rotational bed use, Nolen used a supertrainer approach to reach Baylor’s 3,000 nurses. "Every discipline represented on the team had a part in training the trainer, who in turn saw to it that every person on each unit was trained and recertified on a yearly basis," Nolen says.
Baylor has designated an ICU nurse in each its critical care units as the gatekeeper who evaluates patients daily to make sure rotational beds are being used properly. "The need for continued therapy should be assessed every day, and the bed must be reordered every five days," says Nolen.
Both Nolen and Ebnet suggest to further decrease costs and improve care all patient support surfaces should be evaluated.
"It isn’t as easy as just to stop renting products," says Nolen. "This is just one piece in the wound management equation that balances reducing costs with maintaining quality."
For example, after thorough evaluation of support surfaces, Baylor and Mother Frances decided to purchase hospital-owned beds or rent less expensive beds. The team designed a standardized decision tree for specialty support surfaces that helps clinicians select the appropriate bed. The concept, which includes suggestions of brand names in seven categories of surfaces, also allows for patients to be "stepped up" to a more expensive surface or "stepped down to a less expensive one."
"We also advocate using hospital-owned equipment such as a therapeutic replacement mattress or overlay before renting equipment," says Ebnet. "When renting, start with the lower cost overlays that provide good clinical outcomes. Consider nonpowered or low-air-loss overlays before using low-air-loss beds or high-air-loss beds."
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