As seen in HealthLeaders Media
Published February 5, 2009
By Elyas Bakhtiari
Patient demand for intensive care services continues to rise-but ICUs cost a ton of money. Here's how some providers are making intensive care worth their financial while.
The origins of intensive care medicine supposedly date back to Florence Nightingale, who in 1854 left with a group of volunteers for the Crimean War, where, by separating soldiers for treatment based on the severity of their wounds, she was able to focus on critical cases and reduce the mortality rate from 40% to 2%.
Today's intensive care units are some of the most expensive, and often most sophisticated, areas of modern hospitals. But the same basic principle-allocating resources wisely to improve the quality of the most critically ill patients-remains the key to ICU success. Unfortunately, it's easier said than done.
Most ICUs operate on a 2:1, or even 1:1, nurse-to-patient ratio, compared to 5:1 or higher on the medical floors. Although ICU patients account typically for only 10% to 15% of inpatient beds, they are responsible for up to 30% of acute-care hospital costs. More than $180 billion is spent on critical care in the United States each year.
"The two most expensive parts of the hospital basically are the operating room and ICU, and where it is not done efficiently, intensive care ends up costing the hospital a lot of money," says Tom Rainey, MD, president of the healthcare quality consultant firm CriticalMed, Inc., in Bethesda, MD.
The high costs of intensive care can be daunting at a time when hospitals are forced to make some tough financial choices due to a troubled economy and shrinking margins. But demand for these services will likely only increase as nursing and physician shortages, as well as an aging U.S. population, make delivery more difficult. Ultimately, the financials of intensive care are inextricably tied to the quality and efficiency of how that care is delivered. For hospitals that successfully improve delivery, the savings can total in the millions, and critical care can be viewed as a service line worth investing in rather than solely as a loss-leader.
Success Key No. 1: Close Your ICU
Probably the most significant development in intensive care delivery in the past few years has been the intensivist model, which relies on board-certified critical care specialists to staff and manage hospital ICUs. ICUs were traditionally described as "open" units, meaning any physician in virtually any field could admit and care for a patient. Although many hospitals still operate this way, the industry has come to prefer closed ICUs-where intensivists or other physicians are the primary care agents and ultimately responsible for all medical decision-making.
The closed model, particularly when staffed by intensivists-the two terms are not completely interchangeable, but often go hand in hand-addresses some of the quality and cost problems that arise when various doctors are treating patients without centralized management or clinical decision-making.
"What has evolved is an understanding that intensive care and patients who are critically ill require attention and management 24 hours a day. But medical care has historically been episodic, and the evolution of the intensivist has brought a new level of reliability, proven better outcomes, and [reduced] cost and waste," says Rainey, who is also former president for the Society of Critical Care Medicine.
Because intensivists are trained specifically in critical care, the intensivist model can reduce some of the variation in quality and result in better decision-making when it comes to resource utilization, admissions, and daily care. That's why the Leapfrog Group has included the intensivist model as one of its four major safety practices-and why the Institute for Healthcare Improvement encourages its adoption.
But there's a financial advantage, as well. Significant cost savings accompany improvements in utilization and quality. Physicians in closed ICUs tend to make faster, better decisions so the patients who don't belong in the ICU are triaged beforehand rather than after a costly, unnecessary stay. This type of improved resource management alone can save a 12-bed ICU unit nearly $1 million annually, Rainey estimates. The Society of Critical Care Medicine puts the total potential annual hospital cost savings at $13 million, when quality factors, such as a 14% absolute risk reduction in mortality, are factored in.
Despite the documented benefits, however, only about 25% to 30% of hospitals have adopted some variation of the intensivist model, Rainey estimates. The problem often is competing physician interests, says Ivor S. Douglas, MD, director of the medical ICU at Denver Health Medical Center, a 477-bed level-one trauma center in Colorado. Many nonintensivists are accustomed to ICU access, and hospital administrators are sometimes tempted to endorse the status quo as a way of avoiding a physician relations nightmare. "It boils down to political will within the organization," he says.
For smaller hospitals, the model may just not be practical. "You have to have a certain level of volume to support a full-time intensivist. You need a reasonably sized unit, probably a minimum of eight beds in order to be economically feasible," says Thomas Higgins, MD, chief of adult critical care services at Baystate Medical Center, a 653-staffed-bed level one trauma center in Springfield, MA, that has received the Beacon Award for Critical Care Excellence from the American Association of Critical-Care Nurses four out of the past five years.
Although the main hospital prefers the intensivist model, two of Baystate Health's smaller satellite hospitals aren't big enough to support intensivists, primarily because there isn't enough volume to keep the physicians well-paid and happy. One way a hospital can get around that is by subsidizing intensivists, which is why many intensivists are hospital-employed rather than private practitioners. Another, more preferred option, particularly for smaller ICUs, is to operate instead under an open or modified model that doesn't rely solely on intensivists.
Success Key No. 2: Build multidisciplinary teams
Although intensivists are important, intensive care done right is less physician-centric than most service lines. Physicians, nurses, pharmacists, dieticians, physical therapists, respiratory therapists, social workers, and others are required to deliver 24/7 patient care, so ICU teams must avoid the common pitfalls that accompany hierarchical collaboration.
"Healthcare has become so complex now that no one person has all the information that's needed for the care of a patient," says Higgins. "I rely heavily on my pharmacist to keep track of the patient's organ dysfunction and to make recommendations for dosage changes; I rely on my dieticians to help me order enteral and parenteral nutrition; I rely heavily on nurses to give me information that I may not be seeing on two or three visits a day to the patient but they're seeing by being at bedside 24/7."
While most hospitals pay lip service to multidisciplinary collaboration, achieving it is another matter. For Central DuPage Hospital, a 313-bed hospital in central Illinois, one of the keys was multidisciplinary rounds, which ICU Medical Director Jeffrey Huml, MD, implemented in the fall of 2003 in the 16-bed ICU.
"Within months our length of stay decreased by 1.2 days, our time on ventilators decreased 50%, and risk adjusted mortality markedly improved." To put that in perspective, the Institute for Healthcare Improvement estimates that decreasing length of stay in a 12-bed unit by one day can save $3.5 million every six months and equal to a cost savings of 32 full-time equivalent nurses, Huml says.
Nurses, pharmacists, and other members of the patient team accompany a physician to check on each ICU patient. The benefits are twofold, Huml says. Multidisciplinary rounds serve primarily as an education tool; every member of the team, not just the physician, understands each patient's physiology and treatment plan and is able to intervene in the event of an emergency. That, in turn, affects the group dynamic.
"As the nurse becomes comfortable with the patient's physiology, that nurse becomes an active partner in the patient's care. That has wonderful aspects. One, the nurse feels comfortable challenging the physician on issues. And two, it creates an environment where it's magnetic for nurses to work in because they make a difference at the bedside." Huml says.
In fact, the multidisciplinary rounds were so popular with the nursing staff that night shift nurses who were missing the early rounds wanted to participate as well. So now they do, the difference being they are lead by ROB, a "robotic assisted body" that is controlled remotely by Huml and allows him to see and speak to both nurses and patients via video.
Service Line Success Key No. 3: Collect data
In healthcare, achieving consensus on the importance of addressing a problem is usually easy; it's implementation that typically proves difficult.
For instance, to reduce incidents of ventilator-associated pneumonia, the IHI encourages adoption of a series of interventions known as a ventilator bundle. Most hospitals will agree that the four components of the bundle are important steps in preventing pneumonia, but many don't follow the protocols every day for every patient, says Rainey, who has been chairman of an IHI working group on outcomes improvement for 13 years.
The difference between most of the time and all of the time in the ICU can mean lives. "There's no wonder drug. It's just a matter of closing the gap between good intent and actual execution," he says.
Improving care, particularly when it comes to reducing infections and errors, is a matter of measuring care, then standardizing it. For instance, when Baystate Medical Center began measuring compliance with deep vein thrombosis prophylaxis, one of the components of the ventilator bundle, compliance was just over 50%.
"If you were to query people and ask if they do this for their patients, everyone would say of course they do it. But if you don't measure data then you're not certain what you're really doing," says Higgins. After implementing checklists, posting the results publicly on a quarterly basis, and integrating the procedure into the computer entry system, Baystate was able to bring compliance up to 100%.
Denver Health Medical Center identified three domains-severe septic shock, acute respiratory failure, and hospital-acquired infection-to focus constant quality improvement efforts and incorporate some of the lean process improvement strategies used in other parts of the hospital. But then it went a step further and posts performance results publicly in the ICU.
"We have large wall posters, which are seen by the families of patients, and we report measures like our VAP rates and explain what we're doing to improve things. We view accountability and transparency as a major component of our quality improvement program," says Douglas.
Now that conditions such as catheter infections and ventilator-associated pneumona have been targeted by CMS as "never events," measuring outcomes and implementing protocols for reducing complications on a daily basis is more important than ever.
Success Key No. 4: Subspecialize, if you can
Some strategic considerations can also affect the quality and efficiency of ICU operations. ICUs come in all shapes and sizes-there are neonatal ICUs, pediatric ICUs, neurological ICUs, coronary ICUs, trauma ICUs.
Subspecialized units tend to improve quality through familiarity-physicians and nurses working exclusively on cardiac patients, for example, will be more efficient and efficacious than counterparts who perform the same procedures only periodically in a general medical-surgical ICU.
So when is it advantageous to segment an ICU or add a subspecialized unit? The answer will vary from hospital to hospital and usually depends on volume. For facilities like large academic medical centers, subspecialized units have become standard, whereas smaller hospitals may not have the volume to support a separate unit.
But that isn't always the case. In 2003, Aspirus Wausau Hospital, a 250-staffed-bed level two trauma center in north-central Wisconsin, pulled cardiac cases out of its general ICU to form a small, eight-bed cardiac intensive care unit.
The driver of the change was the cardiovascular service line, says Deb Karow, director of cardiac nursing, who oversees the coronary ICU team. "We are considered a part of the cardiac service line; I report directly to the cardiac service line administrator," she says. "It puts a bit of a different emphasis or imperative in goal setting when you look at contributing to a defined outcomes for a patient population."
Initially the change simply served to segment the existing critical care patients, but over time the coronary critical care patient population grew with the service line. That specialized unit played a major role in national recognition the heart and vascular institute has received, Karow says.
The subspecialization has also been popular with staff, particularly physicians. "If we talked about blending these units back together again we'd have a revolt on our hands. Physicians were instrumental about driving the concept forward. They like the dedicated staff, expertise, the level of trust, the understanding that we're all on the same page looking for the same outcomes."
The Virtues of eICUs
The electronic intensive care unit is often likened to air traffic control. From a single command center, an operator is fed information on dozens of patients in multiple locations and can make split-second decisions to keep the unit running smoothly-or, when necessary, react to a pending disaster.
At UMass Memorial Medical Center in Worcester, MA, a physician and critical care nurse practitioner monitor 10 ICUs at five campuses 24 hours a day via Visicu's eICU program, which includes full audio and visual feeds of every patient bed. The software constantly collects and analyzes data and can detect minor changes in a patient's condition early, and it sends out critical alerts when a patient suddenly takes a turn for the worse-going into congestive heart failure, for instance.
The plethora of data and time-saving features of the eICU have resulted in a shortened length of stay and an overall improvement in mortality rates since its implementation in 2006, says Walter Ettinger, president of the 771-staffed-bed tertiary care center.
Yet most hospitals have been reluctant to adopt eICUs, in part because they believe the costs outweigh the perceived quality improvement benefits. In some cases, particularly for hospitals with smaller ICUs, they may be right.
But the eICU at UMass Memorial has proven to be remarkably sustainable economically, Ettinger says. "In the ICU, hours are important. Because we shortened length of stay, we increased our bed capacity and were able to take more patients. That is what drives the economics of eICU. You're able to get more throughput and in turn bring in more revenue."
Even with a favorable business plan, however, eICU adoption can be a long and potentially divisive process if all parties-boards, leadership, physicians-aren't on the same page. The change at UMass Memorial was driven by a critical care operations committee chaired by a senior critical care physician. One of the committee's goals was to improve quality by ensuring intensivist attendings were available around the clock for patients. There simply weren't enough doctors to pull that off, however, and the committee decided to investigate the eICU as a way of doing more with less.
As shortages of both physicians and nurses trained in intensive care become worse and recruitment becomes challenging, that argument may persuade more hospitals to reconsider eICU technology.