Data help Miami ICU make hard decisions easier
Refined admissions create $800,000 savings
Data can tell you a lot about your ICU, but unless you are willing to act on it, They’re not worth the paper they’re printed out on.So when Baptist Hospital in Miami had a clinical information system in place that produced volumes of data about it’s operation, staff in its Critical Care Center (CC) added another important ingredient — asking why the numbers showed what they did. The answers helped the hospital’s CC to revise its admissions criteria, refine its utilization management, and save the hospital more than $800,000 a year.
The process began after the hospital installed its clinical information system, APACHE III (from APACHE Medical Systems, a software company in McLean, VA). The hospital also adopted a systemwide philosophy based on continuous quality improvement, says. Diane Bolton, RN, director of critical care and acute care services. "We tied all strategies and goals throughout our organization to that. Continuous improvement is our management philosophy."
The new information system included a database of 17,000 patients that Baptist Hospital could benchmark itself against. "One of the first things we noticed was that we had a lot of CC patients who weren’t receiving any kind of therapy that would necessitate a CC admission," says Beth Willmitch, RN, BSN, CCRN, coordinator of the Apache system for the hospital.
That’s because the CC had an open admissions policy, specifically for patients undergoing lower extremity revascularization surgery and carotid endarterectomy. "Before, these patient types were accepted into CC upon physician request," says Bolton. "And, of course, all physicians wanted their patients going to CC because they perceived better care was provided to those patients."
But to better manage expensive ICU resources, the CC management team decided to move toward a more scientific basis for revising admission criteria. Each patient entered into the APACHE III system is evaluated for presence or absence of 33 specific active treatments typically provided in ICUs. If the patient is not receiving one of those treatments, the computer compares the patient’s physiology data to similar patients in the database to determine the chance that the patient will need one of the active treatments, says Willmitch.
If there is a greater than 10% chance that the patient will need one of the treatments, the patient is considered "high risk monitored," and a CC admission is most likely deemed appropriate. If the odds are less than 10%, the patient is considered "low risk monitored" and could be assigned to a less intensive and less expensive area of the hospital.
"We retrospectively reviewed the diagnosis types that fell into the low risk monitored category and used this information to shift patient types from CC to a step down unit and alter CC admission criteria," says Willmitch.
Now, time to convince the doctors
Then came the hardest part of the process — convincing the physicians. "We knew this was going to be hard because this wasn’t the standard in our community," says Willmitch. "Every other hospital in Miami still sends these patients to the ICU overnight or else they stay for extended periods in the recovery room. However, since an extended recovery room stay was not an option for us and we wanted to make our CC units more efficient, utilization of step down units was the best way to go."Despite initial resistance, the CC team was eventually able to sway the physicians to accept the new plan. (For information on techniques used to gain the physicians’ favor, see story, p. XXX.)
Willmitch, an 11-year critical care nurse before she became the APACHE coordinator, says the changes also caused some concerns among the CC staff, primarily from fears that a lower patient load might eliminate jobs. Those fears were never realized because the number of admissions remained the same due to new managed care contracts. "We would have been in a real bind with a 12% increase in admissions if we hadn’t done this," notes Bolton.
Willmitch conducted follow-up studies evaluating equivalency of quality of care between the CC and the step down unit for two types of patients. There was no difference in any outcome measurements between the two groups for femoral bypass patients. The carotid endarterectomy comparison showed a somewhat higher complication rate and a longer hospital length of stay for the CC group. But the APACHE severity of illness score showed those patients to be sicker, which Willmitch says likely accounted for that data.
"The outcomes showed that we had not in any way decreased the quality of care," adds Bolton. "And, in fact, we were able to produce fiscal savings."
That savings amounted to $824,000 in the first year the program was in operation.
Extra costs associated with the changes were minima, and were primarily related to additional hardwire monitoring," says Willmitch.
The CC managers also kept a close eye on the "bounce back rate" — readmissions from the step down unit to the ICU. They found that it actually dropped, from 1.03% in 1994 to 0.52% in 1995.
The changeover took about six months; much of that time was spent on education for the step down staff. That unit was a cardiac unit so the staff already had much of the knowledgeable they needed, says Bolton. "The neuro and vascular piece of it was what they needed," she adds. This was taught by physicians, by working alongside CC nurses, and through a computerized self-study program.
A separate initiative involving group grand rounds also helps keep the most appropriate patients in the ICU. Each morning the physician intensivist going off duty and the one coming on duty conduct rounds to review each patient. The discussion includes individual treatment goals for that day, transfer planning, and any other issues needed "to make sure everyone is on the same page," says Bolton. Besides the intensivists, the rounds include the nurse assigned to each patient, a triage nurse supervisor, a case manager, social worker, pharmacist, and dietitian.
And the patients’ reactions to the changes? "They love it, just love it," says Bolton. "It’s primarily because the CC is a much more restrictive area for family members and patients. And these [step down patients] are not your unconscious, sedated, unaware patients. The step down units are more like a private room setting, and they were very pleased."
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