Care Transitions: From the ED to ICU

Recently I began the series Optimal Outcomes in Care Transitions. The first article in this series focused on outlining the key transition points in patient care and discussed how to evaluate your organization’s performance when transitioning patients from the community into the ED. If you haven’t done so already, I would highly recommend reading the first article in this series before continuing through the care transition process. What you’ll learn is that each part of the series builds on the previous transition in care, and reading the series from the beginning will help connect each of the concepts and help you better understand how each transition can affect the next.

Key Transition Points in Patient Care
In this article, I want to focus on what is often a favorite place for ED physicians to admit patients: the ICU. In today’s healthcare system, intensive care unit costs are a substantial portion of hospital costs and few guidelines exist to establish black and white cases for who should or should not be admitted to the ICU. Given the substantial costs and complexity of admission criteria, it is vital for hospital leaders to understand and manage ICU transitions of care.

First of all, we need to recognize that ED volumes have continued to rise as a result of expanded coverage through the Affordable Care Act, and that ED physicians feel most comfortable admitting patients to the ICU. From there, we need to ask: How much can time in the ICU impact patient care? Here are two examples of how time in an ICU can impact both quality and financial performance.

  • A 2014 study by Johns Hopkins Medicine found that every day of bed rest in the ICU lowers muscle strength by 3% to 11% over following months and even years.
  • A 2013 study by the University of California – San Francisco found that a day in the ICU costs can account for 20% to 30% of all hospital costs.

So here’s what we know:

ED Volumes are Increasing
In March of 2015, the American College of Emergency Physicians surveyed 2,098 of its member physicians to understand how the Affordable Care Act has impacted emergency department volumes. Results from this survey showed that 75% of physicians surveyed had seen an increase in emergency room visits since the launch of the ACA. At a time when hospitals were already struggling to manage ED throughput and improve patient wait times, the challenges have continued to grow with the introduction of additional patients.

ED Physicians Love the ICU
Data from the Center for Disease Control shows that during 2014, emergency room physicians admitted 16.2 million patients with 13% of these admissions going to an intensive care unit. Emergency physicians have stated they feel most comfortable admitting patients to an ICU when they’re unsure how the patient’s condition will progress. While this decision may often be the correct one, patients admitted to an ICU now have one more transition required before they can safely discharge back into the community.

Time in the ICU has a Lasting Impact
A 2014 study by Johns Hopkins Medicine found that every day of bed rest in an ICU lowers muscle strength by 3% to 11% over following months and even years. These effects were seen in some patients as long as 24 months post-discharge. The outcomes from this study demonstrate the lasting effect of slow transitions of care for ICU patients and further underscore the importance for ensuring patients placed in an ICU truly require this level of care.

The ICU is a Huge Cost Driver
While cost per day figures can vary significantly from one hospital to another, the numbers often tell the same story. Spending a day in the ICU will cost you significantly more than spending a day on a medical/surgical unit. How much more? The National Center for Biotechnology Information estimates a day in the ICU will run you six or seven times what it would cost to stay on a medical/surgical unit. They also estimate that each day spent on a medical/surgical unit, rather than an intensive care unit, could yield cost savings of $1,200 per day. Given these findings, it’s easy to see that it may not be how long patients are staying in the hospital – rather, which units they’re staying on – that present a significant improvement opportunity when it comes to reducing cost per case.

So what can you do?
What should you be looking for to ensure the right patients are being placed in the ICU? How should you evaluate if your organization is managing transitions of care effectively for these patients? Below are three metrics you can track to measure how well your organization is managing transitions of care in the ICU and how these metrics can impact care downstream.

Metrics

Like the ED metrics, tracking ICU care transitions and utilization on a daily basis will allow organizations to better manage one of the key drivers for quality and cost outcomes and improve downstream transitions of care. As I always say, no single strategy for managing each of these metrics will work for every organization, so it’s important that leaders revisit strategies that have been implemented to measure their impact and make appropriate adjustments.

Over the coming weeks, I will break down each of the remaining key transition points, discuss what the optimal outcomes are, and provide you with additional metrics to help evaluate how well your organization manages care transitions.

I look forward to continuing this conversation with you.

By Josh Johnson, Consultant

References:

http://www.acphospitalist.org/archives/2013/02/coverstory.htm
http://www.hopkinsmedicine.org/news/media/releases/longer_stay_in_hospital_icu_has_lasting_impact_on_quality_of_life
http://www.cdc.gov/nchs/fastats/emergency-department.htm
http://www.ucsfcme.com/2013/MAN13002/slides/31.%20Dicker%20Cost%20Effectiveness%20in%20the%20Intensive%20Care%20Unit%202013.pdf
http://www.ncbi.nlm.nih.gov/pubmed/7743567

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