How to Cut Costs and Improve Outcomes in the ICU

Two hospitals have demonstrably cut length of stay and improved survivorship among the most vulnerable of patients. Meanwhile, they've increased capacity and improved care.

Anyone who doubts that clinicians can create a virtuous circle of lower costs and improved quality needs to look at the results two hospitals in California and Tennessee have achieved by changing drug and care protocols for their ICU patients.

At its most basic, the change in care protocols involves incorporating evidence that greater use of narcotic pain medications and less use of benzodiazepines in the ICU improves outcomes.

Further, getting patients off sedation, assisted breathing, and up and moving more quickly can cut not only length of stay, but also can improve long-lasting negative effects on patient functionality and even survival.

"More and more data and research shows that some of the meds and treatment strategies used in the ICU contribute to longer stays and delirium," says Krista L. Kaups, MD, director of the surgical ICU at 909-licensed bed Community Regional Medical Center in Fresno, California. "The [medical] community thought long stays and delirium was no big deal for a long time—that's just something that happens with such patients. But those factors have long-lasting effects on patients' ability to recover functionality six months or a year out, so clearly we needed to change our strategies."

Community Regional is one of 77 hospitals that participated in the ICU ABCDEF Bundle Liberation Collaborative organized by the Society of Critical Care Medicine, based on recommendations about the use of ventilators, pain medication, and clinical practices in the ICU that have shown progress in cutting lengths of stay and improving outcomes among ICU trauma patients.

Results of the collaborative, which ran from August 2015 until June 2017, were published in late summer 2017.

Managing pain and sedation

For years, clinicians were trained to keep patients comfortable and sedated, even frequently in medically-induced comas in the critical care unit, says Jeff Wright, MD, medical director of critical care at 800-bed Baptist Memorial Hospital in Memphis, which also participated in the Collaborative.

"But we learned that's probably more dangerous for patients, so we started looking at how to minimize and improve that," Wright says.

One way to improve patient recovery times is to limit the use of benzodiazepine medications, which can contribute to delirium, in favor of narcotic pain management medications, he says.

"We have changed the pain management order set," he says. "How we think about managing pain has changed, with the nursing staff making sure they're adequately assessing people's pain while at the same time helping them get functional."

To help assess pain, the patient must be awake, so if, for example, a patient whose breathing is ventilator-assisted does not have a significant brain injury, respiratory therapists will give them a trial of breathing on their own, says Kaups.

"We have decreased use of benzodiazepines significantly, so our sedation medications are less likely to cause delirium, and we also have changed vent days, which have gradually decreased as has our length of stay," she says.

Mobility and exercise ASAP

Mobility and exercise is also extremely important in improving outcomes and cutting ICU length of stay, says Kaups.

"Even if they have rib fractures and pulmonary contusions, we're going to have them sit up—there's no reason they can't with help and have them get up and walk," she says, noting that even someone who is completely healthy will lose 10% of their muscle strength each day they spend in bed.

"If we don't, they'll see significant amounts of muscle mass loss," she says. "And the more we get people up and moving, the better they do from a delirium standpoint."

Related: Counting Patient Steps Predicts Readmissions Risk

As part of rebuilding the pain medication order sets, Baptist's electronic medical record for ICU patients was modified to make sedation goals more prominent for nurses, as well as modifying care protocols to provide nurses and therapists cohesive and coherent guidelines about getting people out of beds, says Wright.

Emphasis on collaboration

Because so many clinicians interact with ICU patients, teamwork and a cohesive strategy to change protocols is paramount.

Wright says 45­–50 people were involved in the collaborative. Over the course of its participation, Baptist reduced hospital length of stay by about a day, increased overall likelihood of survival by 15%, and reduced the time when patients were in a coma by a similarly dramatic amount, Wright says.

He was most surprised by the increase in survival rate, but says the incorporation of daily multidisciplinary rounds checking on patients "to the point of being boring—every patient, every day—is what it takes," he says.

Wright says that more than 200 nurses had to be trained in a common language and order sets, working together with a core team of physical, occupational, and respiratory therapists.

Wright says about changing care protocols in the ICU: "My advice is go in with an open mind and expect it will take months or years to get it working as well as you want it to, but there's been a dramatic change in how we manage these patients," he says. "Before, if you went in the ICU during the day, most patients used to be asleep. Now they're awake."

Additionally, he says the hospital experienced cost savings of about $800,000 in its first year.

"We didn't hire anyone extra for this project, but I've proposed downstream that we need some more FTEs from the physical and occupational therapy side to get things where we need to be."

Kaups says in addition to better patient outcomes, Community Regional has improved its ability to serve its community.

"We're a Level 1 trauma center and we're always at capacity, so of course it has cost implications," she says. "We're looking at bed capacity and the ability to provide beds when we need them. Anything we can do to decrease length of stay from an economic standpoint is great."

Premier Inc. published a report in late 2017 focusing on ICU trends based on inpatient data from 20 million patient discharges across 786 hospitals over a five-year period (2011-2016).

Patients treated at top-performing hospitals spent 24% less time in the ICU, and the healthcare improvement company said in the same report that with the right tactics, ICU stays within this five-year period could have been reduced by nearly 200,000 days annually. The top 10 ICU diagnoses with the highest variation are as follows:

1. Sepsis patients with major complications or comorbidities: 187,584 potentially fewer ICU days
2. Infectious and parasitic diseases associated with operating room procedures, and major complications or comorbidities: 147,369
3. Cardiac valve and other major cardiothoracic procedures without cardiac catheterization, but with major complications or comorbidities: 121,953
4. Coronary bypass without cardiac catheterization, but with major complications or comorbidities: 97,422
5. Respiratory system diagnosis with ventilator support for up to 96 hours: 94,201
6. Craniotomy and endovascular intracranial procedures with major complications or comorbidities: 88,663
7. Sepsis patients using a mechanical ventilator >96 hours: 67,464
8. Cardiac valve and other major cardiothoracic procedure with cardiac catheterization and major complications or comorbidities: 63,521
9. Cardiac valve and other major cardiothoracic procedure without a cardiac catheterization, but with complications or comorbidities: 60,583
10. Heart failure and shock with major complications or comorbidities: 59,351