SESSION TITLE: Quality Improvement to Improve Patient Safety and Reduce Healthcare Costs
SESSION TYPE: Original Investigation Slide
PRESENTED ON: Wednesday, October 28, 2015 at 07:30 AM - 08:30 AM
PURPOSE: Patients receiving prolonged mechanical ventilation (MV) have high mortality and consume significant health care resources. As part of a performance improvement initiative, we analyzed all such patients in our hospital receiving prolonged MV to better characterize this population and define opportunities for improvement. Based on this analysis, we developed a clinical pathway.
METHODS: For 2012 through 2014, we identified patients at Inova Fairfax Medical Campus receiving MV > 96 hours, via utlization of ICD-9 code 96.72 and determined length of stay (LOS), mortality, and disposition. A clinical pathway was developed targeting the subpopulation receiving tracheostomy, which had the following elements: (1) early identification and performance of tracheostomy; (2) guidelines for early transfer to a long term acute care (LTAC) facility; (3) coordinate rounding with physicians and case management to facilitate transfers; (4) direct physician communication between our hospital and the LTAC for patients with special needs.
RESULTS: For the years 2012, 2013, and 2014 respectively, there were 615, 622, and 626 patients with MV > 96 of whom 32%, 32%, and 31% respectively underwent tracheostomy. In 2012, in-hospital mortality was 18%; 3.5% underwent LTAC transfer, and 61% transfer to a rehabilitation (rehab) or specialized nursing facility (SNF). Our LTAC initiative began in late 2013 and fully was implemented in 2014. For 2013, in-hospital mortality was 16%; 14% underwent LTAC referral, and 55% transfer to either rehab or a SNF. In 2014, mortality fell to 10% and LTAC referrals increased to 26%. Rehab and SNF transfers remained stable at 54%. To verify that LTAC transfer enhanced patient care, we evaluated outcomes for LTAC transfers. Gross LTAC mortality was 7%. 61% were weaned from MV during LTAC stay. From 2012 to 2014, hospital LOS for all patients with MV >96, decreased from 25.7 to 23.1 days, producing an estimated $8.5 million savings based on a reduction of 1,981 hospital days. For the tracheostomy subset, hospital LOS decreased from 36.4 to 29.3 days, a reduction of 1,363 days.
CONCLUSIONS: Implementation of an LTAC referral program for hospital tracheostomy patients resulted in significant improvements in hospital LOS and substantial cost reduction and is associated with reduced mortality in this population.
CLINICAL IMPLICATIONS: Long term MV patients who undergo tracheostomy may be best served by early referral to LTAC. This strategy also is associated with more cost efficient resource utilization.
DISCLOSURE: The following authors have nothing to disclose: Jason Vourlekis, Elisabeth Johnson, Erin Hodson, Svetolik Djurkovic, William Jackson
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