Not so long ago, hospitals relied on consulting physicians (many of them juggling office practices) to care for ICU patients. But research suggests that the sickest patients benefit from intensive, highly specialized care.
The Leapfrog Group, a healthcare quality watchdog organization, recommends 24-7 intensivist staffing
as a "breakthrough" patient safety practice that could potentially save over 50,000 lives a year in the United States.
Full-time intensivist coverage has been shown to reduce hospital-wide mortality by up to 30 percent. Another model with significant benefits is round-the-clock tele-ICU coverage, especially when supplemented by on-site care planning.
Hospitals, however, have been slow to implement this recommendation. Only 44 percent of Leapfrog's 2015 survey respondents fully met the standard.
So what's holding them back? A survey of hospital CMOs and ICU directors
published in the Journal of Critical Care
found that perceived cost was far and away the biggest barrier to implementation.
This is unfortunate, because these fears are generally unfounded. Both financial modeling studies
and our experience at CEP America suggest that a dedicated intensivist service can save its hospital several million dollars each year through operational improvements, cost avoidance, and reduced CMS value program penalties.
What makes me so sure? Well, that's what today's post is all about. Numbers, where not otherwise specified, are derived from our CEP practices. (Special thanks to CEP Intensivist Ian Butler, MD, MBA, who compiled much of the data.)
1. Reduced ICU utilization
The ICU is one of the most expensive places to care for patients. And yet America's ICUs are filled with patients who probably don't need to be there.
Many of these patients were admitted just in case. They'll often be transferred out to make room for more acute cases. In the meantime, they're at increased risk for "overtreatment" with invasive procedures, hospital-acquired infections, and complications like delirium.
The situation is complicated by the fact that there are few evidence-based guidelines for ICU triage.
That's where the judgment of a dedicated intensivist can make a difference. They're in the best position to judge who needs specialized critical care and who might do just as well in a regular inpatient unit.
In the past year, CEP Intensivists reduced ICU utilization at one of our hospitals by 5 percent. The result: an estimated cost savings of $750,000 to $1.5 million for a 24-bed ICU with 80 percent occupancy.
2. Shorter ICU length of stay (LOS)
More so than consultants, dedicated intensivists can judge when an ICU patient is ready to be moved to a lower level of care. At integrated CEP sites, intensivists can work with CEP Hospitalists to facilitate smooth, coordinated transitions of care out of the ICU that create a satisfying experience for the patients and their families. Intensivists can also work with staff to monitor patients for delirium and other complications that increase LOS.
When one of our hospitals implemented a full-time intensivists service, LOS immediately dropped by half a day and remained consistently low. Decreasing LOS by 13 percent saved that unit 900 bed days — or an estimated $2–4 million — over the course of a year.
3. Fewer ventilator associated events (VAEs)
Increased ventilator utilization is associated with longer ICU LOS. It also increases patients' risk for VAEs, including pneumonia, sepsis, and pulmonary embolism.
VAEs are among the most deadly of the hospital-acquired infections (HAIs). They're also very expensive to treat, averaging $17,000–$41,000 per case. And high rates of HAIs at your hospital can incur significant financial penalties from Medicare and other payers.
One CEP Intensivist practice reduced ventilator days by 13 percent and VAE cases by 66 percent over the course of a year. Their approach involved twice-daily multidisciplinary rounding with the aim of weaning ventilator patients as soon as safely possible. They also implemented a checklist covering oral care, bed elevation, and mobility.
4. Fewer catheter associated urinary-tract infections (CAUTIs)
CAUTIs are probably the most common HAIs that occur in the ICU. And unfortunately, they're tracked and penalized by Medicare.
The best CAUTI prevention strategy is to reduce catheter days. We've seen intensivist practices reduce CAUTI cases by as much as 10 percent after implementing a catheter necessity checklist on daily rounds.
5. Fewer central line associated blood infections (CLABSIs)
Again, reducing central line days is the best defense against this HAI, which carries a 12–25 percent mortality rate
and costs up to $36,000 per case to treat. Dedicated intensivist care can result in more rigorous monitoring and earlier removal.
6. Fewer medical errors
Medical errors can cause care costs to spiral. Increases in morbidity and LOS add up fast, as do value-based purchasing penalties. And then there's the added risk of a lawsuit.
The intensivist practice model emphasizes one of the best safeguards against error: teamwork. Providers, nurses, therapists, pharmacists, dietitians, and social workers round together on patients — sometimes multiple times a day. Each discipline follows a set of standardized, evidence-based practices designed to keep patients safe.
Other error-prevention strategies implemented by CEP hospitals include:
- Evidence-based order sets and safety protocols (e.g., sedative de-escalation)
- Checklists for central lines, urinary catheters, glucose control, and more
- Appropriate ICU utilization to reduce transfers
- Face-to-face handoffs during admission and discharge
7. Improved case mix index (CMI)
From major complicating conditions to more subtle issues, intensivists are adept at documenting their patients' clinical course and complexity. This wealth of information is later passed on to the hospitalist team, helping them to document more completely. The result: a more favorable CMI and more equitable reimbursement for the hospital.
8. Timely palliative care referrals
A quarter of all Medicare dollars are spent on patients in the last year of life
. In many cases, these go for aggressive therapies that are unlikely to prolong life — and may even cause undue distress to the patient and family.
By contrast, a timely conversation about a patient’s goals of care can empower patients while stewarding healthcare resources. Intensivist providers generally have a good handle on their patients' prognoses, allowing them to initiate these conversations as early as is appropriate.
In addition, palliative care providers often join in multidisciplinary ICU rounds to provide comfort to patients and expert guidance to the team.
9. Nursing and staff engagement
The average hospital loses $5–$7.5 million to nurse turnover
each year, according to Becker's Healthcare. Here are just a few of the ways that a dedicated intensivist service can promote nurse retention:
- Multidisciplinary rounding
- Committee participation and leadership
- Advanced educational opportunities
- Code debriefing
- Research opportunities
So what does this look like in action? Well, the nurses at one of our sites are currently developing a delirium screening protocol for the ICU. The physicians updated their code blue procedural handbook to further empower nurse decision-making. And intensivist providers and nurses are collaborating on quality research with the goal of publication.
10. Quality improvement
Intensivists can have an impact far beyond the ICU walls. Their expertise helps to improve patient outcomes, decrease mortality, improve utilization, and enhance quality across the hospital.
Here are just a few of the hospital-wide committees in which CEP Intensivists currently participate as part of their commitment to improve quality:
- Critical care
- Antibiotic stewardship
- Infection control
- Code Blue
- Pharmacy and therapeutics
- Cardiac surgery
- Peer review
- Utilization review
The value of all that engagement is hard to quantify in dollars. But we're pretty certain it adds up to enhanced performance in the CMS value programs. All of which can really pay off for your hospital.
Still worried about costs?
If implementing 24-7 intensivist coverage still sounds like an expensive order, consider alternative payment models. It's often possible to negotiate a performance-based contract, bundled payments, or shared savings with an intensivist practice. Your costs will be more predictable, and the group gets the benefit of a larger potential payoff.
How does your hospital handle ICU coverage? And what are the pros and cons of that approach? Comment and tell us about it!