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."