Moving Out of the ICU
Across the US, the dramatic rise in ICU bed utilization might be considered good economic news: filling hospital beds is generally good business for a hospital. But not in the case of long-term ICU beds. That’s because most patients on ventilators are covered by Medicare, and hospitals receive the same flat DRG payment for these patients, whether they stay one day or six months. With many patients staying months at a time, hospitals are facing significant cost overruns.
Those trends became apparent at the Luther Midelfort — Mayo Health System, in Minnesota, where Mark Lindsay, MD, is chair of the department of pulmonary and critical care medicine. In 1997, Lindsay decided it would be a good idea to move many of these long-term ventilator patients from the hospital ICU to the ventilator unit at the Lakeside Nursing Home, which had vacancies. He calls it an example of “shared opportunities” for both facilities. Seven years later, the project is doing remarkably well. It has led not only to cost savings, but also to better care. “We’re talking about millions of dollars,” says Lindsay. “More importantly, we can dramatically improve the care of these patients.”
The results are striking. From 1987 to 1997, the nursing home had 11 patients on ventilators. Only one patient was weaned successfully, and the majority died. Compare that with the results from 1997 to 2002, while the project was in place: the nursing home had more than 100 ventilator patients, and 67 percent of them came off their ventilators.
How did they do it? Lindsay points to training and dedication as major factors. His practice convinced a top respiratory therapist to move from his position at the hospital to become director of the nursing home’s ventilator unit. It wasn’t an easy decision for the therapist, says Lindsay, who says he was able to convince him by explaining that staff empowerment and other factors would lead to success.
One important success factor was introducing user-friendly protocols for weaning. “Protocol-based weaning is more effective than relying on physicians’ orders,” Lindsay explains. Another factor was something he learned at IHI: the concept of bedside rounds
coupled with a goal sheet
. Every Wednesday at 1:00 PM, the entire team — nurses, certified nurse assistants, respiratory therapists, social workers, and doctors, along with family members — meet at the patient’s bedside. “It’s key that everyone is on the same page for that patient,” says Lindsay. And despite the fact that some of the patients have been on ventilators for five years or more, the team still asks each one about their needs and about any problems.
The program also emphasizes socialization and the importance of getting patients out of their rooms. “Most of them had never left their rooms in the ICU” in the hospitals they came from, Lindsay says. Using a simple trach collar to wean patients, the staff dresses them in regular clothes and gets them out of the unit.
Better patient care is just one of the benefits. These changes, among others, have reduced high turnover, which can approach 100 percent per year in some nursing homes. “Putting these partnerships together empowers staff,” Lindsay says. “We have had very low turnover rates.” The physician team that runs the ventilator unit at the nursing home also runs the ICU at one of the hospitals and gets production credit for the days spent caring for ventilator unit patients at the nursing home, so they have an economic incentive as well.
Saving Lives — and Millions
The cost savings are considerable. Lindsay estimates that the program has saved the 20 participating hospitals some $18.5 million — based on 15,384 ventilator days, at $1,200 per day, with the DRG covering only the initial day. In contrast, the nursing home, which can collect reimbursement for its ventilator unit, spends $300 per ventilator day. Because of the economies of scale, among other factors, the program is profitable for the nursing home which has asked to expand the unit.
Lindsay emphasizes that the 67 percent weaning rate is real, and not the result of self-selection of patients. Among the nursing home patients, 28 percent have had neuromuscular diagnoses — those that predict the least likelihood of weaning — while other units, with lower weaning rates, had only 10 percent of patients with such diagnoses. Other units have had lower rates of successful weaning, at higher cost. This reinforces Lindsay’s contention that “ICUs are not necessarily the best place” for patients chronically on ventilators.
Taking Success on the Road
Lindsay wanted to take the concept of shared opportunities beyond nursing homes. So he took it to a rural hospital, which, like many others, was having trouble competing with major medical centers. He wanted to develop a transitional care unit at the underutilized hospital for patients who were not on ventilators but were chronically ill. He received permission to conduct a six-month pilot program and began sending patients who needed rehabilitation from Luther Hospital, the major medical center, to the rural hospital. The program freed up beds at Luther and occupied beds in the rural hospital, which benefited both facilities.
With the influx of patients, along with the 1997 critical hospital designations that gave the rural hospital cost-based reimbursement, the rural hospital reversed a 10-quarter-long negative income streak in mid-2001. Since then, all but one quarter has been income-positive. “More importantly,” says Lindsay, “4,500 patients were cared for, and we expanded and opened up new beds in the tertiary facility.”
Lindsay says there are a number of other potential shared opportunities. He has worked with cardiovascular surgeons at his hospital on a post-CABG rehabilitation program. The surgeons weren’t happy with the level of care their patients were getting in nursing homes, finding that they had frequent morbidities and readmissions to the hospital. When the cardiovascular rehabilitation program began, it had only one patient; today, it has an average of 12 patients, and the surgeons are so pleased with the results that they have committed to training additional staff in their protocols.
Lindsay cites the high rate of infections among nursing home patients as another area that could benefit from a shared project. “There really are tremendous opportunities to develop partnerships with nursing homes” and other facilities, says Lindsay. “If we don’t invest in our nursing homes, it will impact our ability to discharge our patients safely from our hospitals,” he adds.