REDUCING LENGTHS OF STAY IN THE CORONARY-CARE UNIT WITH A PRACTICE GUIDELINE FOR PATIENTS WITH CONGESTIVE-HEART-FAILURE - INSIGHTS FROM A CONTROLLED CLINICAL-TRIAL

Although more than 1,000 medical practice guidelines have been develop ed, there have been few evaluations of their use in clinical practice or information to judge whether practice guidelines can be used to red uce health care costs. For this reason, the authors conducted a prospe ctive controlled clinical trial with an alternating-month design at a large teaching community hospital to study the use of a practice guide line to promote early transfer of patients admitted to a hospital with congestive heart failure (CHF) from the coronary care unit (CCU) and intermediate care unit to unmonitored beds. The practice guideline was supported by locally derived risk information and recommended conside ration of early ''step-down'' transfer of low-risk patients with CHF 2 4 hours after hospital admission. Physicians caring for patients ident ified as ''low risk'' received concurrent personalized written and ver bal reminders concerning the guideline recommendation. Study subjects were patients admitted to a hospital CCU and intermediate care unit be tween November 1, 1991 and April 30, 1993 with a diagnosis of CHF or p ulmonary edema. Ninety patients with CHF were identified as low risk a ccording to the guideline during the study period. Feedback of the pra ctice guideline recommendation was not associated with a significant i ncrease in physician adoption of the guideline or shorter lengths of s tay in the CCU or intermediate care unit. Physicians may have compensa ted for statistically insignificant reductions in monitored lengths of stay by increasing the length of stay in unmonitored beds (1.80 +/- 2 .32 to 4.02 +/- 4.09 days, P = .002) and the total length of stay (4.7 3 +/- 2.43 to 6.71 +/- 5.44 days, P = .03). Quality of patient care, p atient outcomes, and patient satisfaction were not affected by the gui deline. Our study results suggest that implementation of a locally der ived practice guideline for patients with CHF did not result in adopti on of the guideline by physicians. The complexity of implementing the guideline, changes in physician practice before the study, and the fai lure of the guideline to address the continuum of patient care across monitored and unmonitored beds may have accounted for rejection of the guideline. Our experience demonstrates that practice guidelines, when ever possible, should be evaluated in prospective trials before they s hould be disseminated for widespread use.