Cost-containment Protocol That Reduces Length of Stay and Improves Outcomes for Neurosurgical Patients

Joshua E. Medow, MD, MS, Department of Neurological Surgery, University of Wisconsin, Madison, Wis.; Brandon G. Rocque, MD, MS, Department of Neurological Surgery, University of Wisconsin, Madison, Wis.; Daniella Micic, MD, Medical College of Wisconsin, Milwaukee, Wis.

Correspondence to: medow@neurosurgery.wisc.edu

Abbreviations: LOS, length of stay; NSICU, neuroscience intensive care unit; UHC, University Health Consortium; LTACH, long-term acute care hospital

Key Words: cost containment, practice management, healthcare, reimbursement, discharge procedure

Received: June 08, 2011

Accepted: July 05, 2011

Disclosure: The authors reported no conflicts for disclosure.

Abstract:In this evolving world of health-care reimbursement, certain factors such as patient length of stay (LOS) can significantly impact hospital costs. With fewer dollars available and an expected explosion of admissions in the coming years, hospitals will need to effectively and efficiently provide quality care. We developed a protocol that promoted faster bed turnover and simultaneously permitted low mortality rates in our Neuroscience Intensive Care Unit (NSICU). This not only allowed more patients to receive care, but also significantly reduced direct costs for the institution. By promoting efficiency in the discharge process, hospitals can significantly decrease costs and help more patients get the care that they need.

Introduction
Intensive care units (ICUs) provide acute life-sustaining care for the sickest patients in the hospital and, as such, consume a significant amount of health-care resources. Demand for ICU beds also is growing as the population ages and as technology allows physicians to prolong life for the chronically critically ill (10, 15, 38). For these reasons, ICUs often are targets for quality-improvement projects geared toward identifying ways to decrease resource use (4, 34). Neurosurgical patients often are at the extreme end of resource use, requiring procedures, expensive medications and life-supporting devices. For this reason, neuroscience ICUs and their practices should be studied in depth to identify ways that quality care can be provided at reduced costs.

ICU care costs approximately four times more than routine hospital care (39), and often accounts for a disproportional amount of hospital resources (17). While ICUs make up approximately 5-10 percent of all hospital beds, they consume between 20-34 percent of hospital resources, ultimately accounting for approximately 1 percent of the United States’ total gross domestic product (9). While the number of hospital beds and inpatient days in wards has decreased from 1985 to 2000, the number of ICUs and days spent in them has increased over that same time period (18). Patients with increased LOS in the ICU use a disproportionate number of resources, and have higher mortality rates. One study showed that patients who stayed in the ICU more than seven days used more than 50 percent of all ICU resources (36), and patients who had ICU admissions 14 days or longer had a mortality rate of 50 percent (31,40). Furthermore, it has been shown that resource use in the ICU is directly related to the patient’s LOS within the ICU (8).

Many studies have looked at ways to predict patient LOS in the ICU, but did not look at ways to reduce the LOS (3, 22-24, 30, 41). Identifying patients at risk for prolonged LOS in the ICU may improve early discharge planning by helping to determine other care alternatives (24, 30). We decided to implement a protocol within the neuroscience ICU to encourage early completion of either advanced directives or legal guardianship, to help guide placement once a patient was medically suitable for discharge.

It is well known that many patients lack decisional capacity at times when important treatment decisions need to be made (20, 28, 35). This is especially true for patients in neurocritical care (27). However, autonomy still is encouraged among these patients. Ever since the Patient Self-Determination Act was implemented in 1990, patients have been required to be aware of their right to autonomy, and they are encouraged to execute advanced directives (AMA Physician and Public Attitudes on Health Care Issues, 1989). However, literature shows that only 5-35 percent of patients admitted to health-care facilities have advanced directives in place (16, 21, 29, 37), and many patients refuse to document advanced directives even during hospital admission. In a small study performed at one hospital, Allen et al showed that 82.4 percent of patients denied having advanced directives on admission, and only 40.9 percent of these patients went on to complete advanced directives during their hospital stay (2).

When an adult patient is considered to lack decision-making capability and there are no advanced directives or other legal appointments in place, decisions can become complicated, as physicians involve close family and friends for treatment planning (19, 27, 28). However, disagreements between patient’s families and physicians often can cause difficulties that delay both treatment options and decision-making, prolonging ICU and hospital LOS (5, 11). For this reason, and because of laws specific to the state of Wisconsin (Editor’s Note: See the Discussion section below for details on those laws.), we formulated a protocol to assess for the presence of advanced directives, obtained advanced directives early when possible in those cases where they were not already existent, and defined the various plans of care for patients and families when care was likely to be protracted. The purpose of this study is to report the impact of implementation of this protocol on patient LOS.

Methods
Beginning in August of 2008, we implemented a patient disposition protocol to require: 1) social work or nurse case manager contact with family within 24 hours; 2) a determination whether a health-care power of attorney exists within 48 hours; 3) obtaining a health-care power of attorney immediately for patients with decision-making capacity; 4) initiation of the legal guardianship process within 72 hours, if deemed appropriate; and 5) filing of the legal guardianship application within seven days of admission.

All neuroscience ICU patients that were either discharged directly from the ICU or transferred to general care prior to discharge from August of 2007 through July of 2009 served as the searchable patient population. The 2007-2008-year patients formed the control group, while the 2008-2009 patients represented the intervention group. The number of discharges in each year was tracked. The average length of stay for a given primary diagnosis code was compared to the national target length of stay from University Health Consortium (UHC) data. The results of this differential were averaged for each 12-month period. The direct costs of patient care for a single day in the ICU during the intervention year were used to calculate the overall direct cost-savings for that year as compared to the prior (control) year.

Cost Definitions
Direct costs refer to those costs that the hospital incurs to care for the patient (nursing hours, medications used, labs/studies, etc). This is in contrast to indirect costs, which are a reflection of global hospital expenses (i.e., salaries of administrators, cleaning crew, utilities, etc). Billing data describes what charges were levied to the patient and/or their insurance provider. Billing charges were not used in the calculations for this study because of the vast discrepancies in the dollar amounts collected from patients and insurance programs. Indirect costs were not used because of the inability to fairly divide out global hospital costs amongst our particular neuroscience patient group. Subsequent discussion of costs will report direct costs only.

Results
The total number of patients with any documented ICU stay discharged in the 2007-2008 control year was 1,604 as compared to 1,901 for the 2008-2009 intervention year. The total difference in the number of discharges was 297 patients. Using a diagnosis-based expected length of care calculated by hospital administration as the “expected” length of stay, the control year had a total patient LOS that was 18 days fewer than predicted, whereas in the 2008-2009 group, LOS was 278 days fewer than predicted (Figure 1). Compliance was 100 percent. The decrease in LOS was statistically significant, using a two-tailed t test with a P value equal to 0.0148. Twenty-nine patients were discharged to a long-term acute care hospital (LTACH) in the 2008-2009 group vs. no LTACH discharges in the prior year. The discharges to LTACH likely improved in the study group because there was limited knowledge of the LTACH and its ability to accept neurologically compromised patients in the previous year. The mean LOS per patient decreased by 0.77 days. Based on this reduction in ICU LOS, the hospital saved an estimated $2.66 million in the year after implementation of the protocol. During this same time frame, mortality, as compared to UHC predicted outcomes data, was lower than the national average by 44 percent in patients ventilated > 96 hours, by 12 percent in patients ventilated < 96 hours, and by 27 percent in patients not ventilated at all. In the prior year, mortality was slightly better than the UHC reported national average. This indicated that mortality was substantially improved in the study group as compared to the control group.

Discussion
In the state of Wisconsin, a patient cannot be admitted to a nursing care facility or rehabilitation center without an advanced directive or legal appointment in place (WI Statute Ch. 155). This creates a unique situation in which a patient who is incapable of making his own decisions cannot be discharged from the hospital to a nursing or rehabilitation facility without a health-care power of attorney or court-appointed guardian. Therefore, LOS often is prolonged both within the ICU and the general care ward as patients await completion of legal documents for discharge. The protocol described in this study attempted to reduce length of stay by facilitating early consideration of the documentation necessary for discharge. In the control year, patients’ families were not approached for guardianship until after one week and the time to making this approach was not standardized. During the intervention year, the number of patients that were approached after one week in the control group, however, was 11, and the average length of time was approximately 10 days (excluding one patient that was 32 days). These delays were generally physician-related.

A University of Michigan study showed that delayed discharges were due to late referrals for discharge planning, non-completion of required transfer forms, unavailability of appropriate post-hospital beds and unanticipated changes in the patient’s medical condition (33). Social workers facilitate the process of obtaining consent through advanced directives, legal appointment of a health-care power of attorney or guardianship process (13). Likewise, a small study performed in the Netherlands found that 30 percent of hospital stays for trauma patients were inappropriately long and, of those, 18 percent were due to delayed discharge planning. By planning for discharge on the day of the patient’s admission — rather than after the patient’s surgery — this study showed that LOS could be decreased by an average of 2.9 days and save the hospital more than 175,000 euros (26). Our protocol mandates early involvement of social workers in an effort to reduce impediments to appropriate patient discharge or transfer to other facilities. Compliance with the protocol was 100 percent over the study year.

Other studies have shown that various patient-care protocols can decrease patient LOS. Implementing a communications team to increase understanding the plan of care by patients and/or family members can decrease LOS (1), as can providing an ethics team to discuss patient prognosis and treatment options (12, 32). Increasing feedback and communication among physicians that care for the same patients also can lead to a shorter ICU LOS (14). Involving a palliative care team decreased the time to obtaining consensus amongst patients and families about a dismal outcome and permitted the implementation of comfort measures, therefore decreasing overall ICU LOS (6, 7). Using intermediate care units or progressive care areas for patients with prolonged length of stays can decrease expensive ICU resource use (25, 30). Our protocol also utilized LTACHs as an alternative discharge option for patients who remained critically ill or in need of acute care, but no longer had neurosurgical or neurocritical care needs. While there were only 29 discharges to LTACHs during the study year, these patients may have significantly contributed to the decrease in LOS, since they were likely to have prolonged hospitalizations. However, there is no way for us to know exactly how much the LTACH affected LOS given that we do not have access to their records, but it would appear that as much as 30 percent of the 278-day reduction in LOS could have been related to the LTACH. However, not all patients qualified for LTACH transfer. Those patients that were transferred did require the appropriate advanced directive or guardianship process before transfer could occur. Patients also needed to have multiple medical needs including ventilation support beyond the scope of a general care floor at our institution. This generally included the use of continuous bi-level positive airway pressure (whereas continuous positive airway pressure was not a problem for the general-care floor patients at our hospital). The LTACH was never used as a stopgap for patients requiring a skilled nursing facility.

It also is important to note that during the study period, the overall mortality for patients discharged from our ICU was significantly lower than the national average. Our rate of readmission for the same Major Diagnostic Category (MDC) within 30 days was 7.65 percent; for the same Diagnostic Related Group (DRG) within 30 days, the rate of readmission was 1.09 percent. Thus, it can be concluded that our protocol for decreasing ICU LOS is not leading to inappropriate or premature discharge from the ICU or from the hospital. However, it should be noted that during the study period, more than 20 quality-improvement initiatives were implemented in the neuroscience ICU. Any of these changes may have contributed to the decrease in the LOS and our low overall mortality. However, the simplicity of the protocol described here and the fact that the LOS was profoundly improved after implementation of the protocol make this study valuable, despite the potential confounders.

Conclusion
A simple protocol involving early involvement of social workers and case managers, early assessment of the existence of health-care power of attorney documents, expedited completion of these documents or guardianship applications, and utilization of other patient-care resources such as the palliative care service, LTACHs, etc., can lead to significant decreases in patient LOS in the neuroscience ICU.

Joshua E. Medow, MD, MS; and Brandon G. Rocque, MD, MS, are members of the Department of Neurological Surgery at the University of Wisconsin in Madison, Wis. Dr. Medow is the director of neurocritical care, and Dr. Rocque is a chief resident. Daniella Micic, MD, is a resident physician at the Medical College of Wisconsin in Milwaukee.

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