Abstract :
ISSUE: Physicians form opinions about the resources and level of care in hospitals. These perceptions can play a role in clinical decision-making. At the Veterans Affairs Medical Center (VAMC) in Lexington there has been a perception among physicians that patient care provided in the intensive care units (ICUs) is of a higher quality than that on the acute-care units. This perception leads to patient transfer delays out of the ICU even when the patientʹs condition meets transfer criteria. The most frequent reason cited in utilization management (UM) data for the delays is “physician preference,” which results in excess ICU days. To test this perception Infection Control undertook the task of establishing a baseline for evaluating respiratory care provided on the acute-care units.
PROJECT: Nosocomial pneumonia rates were selected as the indicator for respiratory care outcomes. The population studied was all surgical patients admitted to an acute-care unit. Since this VAMC participates in the National Nosocomial Infections Surveillance (NNIS) system, the NNIS definition of nosocomial pneumonia was used. A literature search was done to provide benchmark data. Monthly reports were issued to Patient Care Services and UM, which in turn provided feedback to the physicians.
RESULTS: The mean nosocomial pneumonia rate for the acute care unit was 2.3 cases per 1000 bed days of care, while the ICU mean was 4.4. An incidence of 0.7% compares favorably with National Surgical Quality Improvement Program (NSQIP) reported incidence of 1.5%. Using nosocomial pneumonia rates as an indicator of quality of care, the acute-care unit provides a comparable level of care. After feedback began to be provided to physicians the number of excess ICU days attributed to “physician preference” declined from 80 days in the first quarter of the fiscal year to 14 days in the fourth quarter. With the ICU cost per patient day at $4198 and the acute care unit cost at $1953, the reduction in excess ICU days results in a cost avoidance of $148,170.
LESSONS LEARNED: Providersʹ perceptions probably do influence clinical decisions, but surveillance data can impact those perceptions. Avoiding excess ICU days can reduce costs without placing patients at risk.
