Cost reduction and outcome improvement in the intensive care unit

Objective: Decreasing reimbursement provided by third-party payers necessit ates reduction of costs for providing critical care services. If academic m edical centers are to remain viable, methods must be instituted that allow cost reduction through practice change. Methods: We used short cycle improvement methodology to rapidly achieve the se goals, Short cycle improvement methodology involves identifying the area s for improvement, defining a mechanism to evaluate outcome, initiating an improvement plan on a small number of patients, and repeating the cycle wit h new adjustments based on outcome. Baseline data on areas for improvement was prospectively collected, and protocols to initiate change were develope d and tested by short improvement cycles, Outcomes were evaluated, protocol s were modified, and another cycle was performed. This methodology was cont inued until the desired goals had been achieved. To adjust outcomes for sev erity of illness, Acute Physiology and Chronic Health Evaluation II methodo logy was used. Using this methodology, we focused on three areas for improv ement, Standing orders for laboratory studies, electrocardiograms, and ches t x-ray films were eliminated. Protocols were developed for the appropriate use of sedation, analgesics, and neuromuscular blocking agents. Finally, a protocol for weaning from mechanical ventilation was developed to allow re spiratory therapists to proceed through the weaning process, which was orde red by a physician, Results: Laboratory tests were reduced by 65% (from 510 to 180 tests per da y) with an annual cost savings of $21,593, Chest x-ray reduction of 56% res ulted in an annual savings of $3,941, There was a 75% reduction in cost of neuromuscular blocking agents. The use of neuromuscular blocking agents res ulted in a 75% reduction in drug costs. Ventilator hours were reduced by 35 % from 140 to 90 hours, The average length of overall intensive care unit s tay was reduced by 1.5 days (5.0 to 3.5 days), The cost per patient day dec reased with an annualized cost savings of 4% per patient day. Unexpected ou tcomes included a reduction in intensive care unit days from 54 days at bas eline to 7 days at the 6-month interval, The infection rates for blood stre am infections, urinary tract infections, and nosocomial pneumonia were redu ced. Using national nosocomial infection data, these rates represented a re duction from the fiftieth percentile to the twenty-fifth percentile for all measured indicators, Acute Physiology and Chronic Health Evaluation II sco res were 19.54 at baseline and increased to 21.2 (p = 0.001) at the 6-month interval. Mortality rates were 16.7% at baseline and were 17.6% (p = 0.89) at the 6-month interval. Conclusion: We concluded that utilization of short cycle improvement method ology provided an ongoing method for reducing costs of critical care servic es in our patient population with no change in mortality.