Decreasing reimbursement provided by third-party payors necessitates reduction of costs for providing critical care services. If academic medical centers are to remain viable, methods must be instituted that allow cost reduction through practice change.
We used short cycle improvement methodology to rapidly achieve these goals. Short cycle improvement methodology involves identifying the areas for improvement, defining a mechanism to evaluate outcome, initiating an improvement plan on a small number of patients, and repeating the cycle with new adjustments based on outcome. Baseline data on areas for improvement was prospectively collected, and protocols to initiate change were developed and tested by short improvement cycles. Outcomes were evaluated, protocols were modified, and another cycle was performed. This methodology was continued until the desired goals had been achieved. To adjust outcomes for severity of illness, Acute Physiology and Chronic Health Evaluation II methodology was used. Using this methodology, we focused on three areas for improvement. Standing orders for laboratory studies, electrocardiograms, and chest 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 respiratory therapists to proceed through the weaning process, which was ordered by a physician.
Laboratory tests were reduced by 65% (from 510 to 180 tests per day) with an annual cost savings of $21,593. Chest x-ray reduction of 56% resulted in an annual savings of $3,941. There was a 75% reduction in cost of neuromuscular blocking agents. The use of neuromuscular blocking agents resulted 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 stay was reduced by 1.5 days (5.0 to 3.5 days). The cost per patient day decreased with an annualized cost savings of 4% per patient day. Unexpected outcomes included a reduction in intensive care unit days from 54 days at baseline to 7 days at the 6-month interval. The infection rates for blood stream infections, urinary tract infections, and nosocomial pneumonia were reduced. Using national nosocomial infection data, these rates represented a reduction from the fiftieth percentile to the twenty-fifth percentile for all measured indicators. Acute Physiology and Chronic Health Evaluation II scores 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.
We concluded that utilization of short cycle improvement methodology provided an ongoing method for reducing costs of critical care services in our patient population with no change in mortality.
From the Department of Surgery, University Hospital, Syracuse, New York.
Presented at the 58th Annual Meeting of the American Association for the Surgery of Trauma and the Trauma Association of Canada, September 25, 1998, Baltimore, Maryland.
Address for reprints: William H. Marx, DO, Department of Surgery, Room 8801, University Hospital, 750 E. Adams Street, Syracuse, NY 13210.