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Cost-Containment Project: “ Just a Liter of Normal Saline”

Cost-Containment Project: “ Just a Liter of Normal Saline”. Mohammad Usman Qazi, PGY2 Department of Internal Medicine. Goal. Project goal: To determine if prescription of intravenous fluid therapy in medicine admissions is appropriate

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Cost-Containment Project: “ Just a Liter of Normal Saline”

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  1. Cost-Containment Project: “Just a Liter of Normal Saline” Mohammad Usman Qazi, PGY2 Department of Internal Medicine

  2. Goal • Project goal: • To determine if prescription of intravenous fluid therapy in medicine admissions is appropriate • Calculate cost of IVF therapy to the hospital in cases where it is not indicated (both on admission and maintenance) • Identify areas for improvement

  3. Intravenous Fluid Therapy • Inclusion Criteria: • Admission to med/surg or telemetry floors from ED or transferred from ICU • Exclusion Criteria: • Patients transferred from OSH • Patients admitted with septic shock

  4. Indications for IVF: • Indications for the prescription of intravenous fluids I. Highest priority a) Defend hemodynamics 1. Re-expand a severely contracted ECF volume 2. Prevent a fall in blood pressure when venous tone is low (e.g., anaesthesia) b) Return the ICF volume towards normal 1. Acute hyponatraemia that is symptomatic 2. Chronic hyponatraemia with a seizure 3. Chronic asymptomatic hyponatraemia II. Moderate priority 1. Re-expand a modestly contracted ECF volume Replace ongoing losses Avoid oliguria Match estimated electrolyte-free water loss in sweat and in the GI tract How to select optimal maintenance intravenous fluid therapy. Shafiee M, Bohn D, Hoorn E, et al. Q J Med; 2000. 96:601-610

  5. Study Methods • Admission IVF Indication: • Severe sepsis • Any hemodynamic instability (due to GI bleed etc) • Fluid resuscitation (diarrhea, vomiting, pancreatitis, acute kidney injury, DKA) • Burns • Maintenance IVF indication: • Patient NPO • Patient with poor nutritional intake • Correction of electrolyte abnormalities • Oliguria and/or AKI

  6. Methods Continued: • Randomly selected 22 participants from patients (55 total) currently on the 6 medicine services at UCI Medical Center. • Exclusion and Inclusion criteria utilized • IVF boluses given at admission recorded as well as any maintenance fluid started (with duration) • Diet Recorded • Charts reviewed, and if no mention of poor nutrition assumed patient eating diet • Recorded L of IVF given on admission where not indicated  cost per admission calculated • L of maintenance IVF used per day recorded in patients where IVF not indicated  cost per day calculated for % of patients where IVF not indicated Please see supplementary information for table

  7. Results: • Number of Patients: 22 • Patients given IVF on Admission: 16/22 • Patients where IVF was indicated on Admission: 4/16 (25%) • Total Liters of fluids given on admission to 12 patients where they were not indicated: 19.3L • Avg L/admission: 1.6L • Avg cost of 1L Bag of IVF: $10 • Cost/admission to medicine: $16/admission • Average # of admissions to medicine/day: 10 (75% with no indication for IVF) • Cost/day of admissions when IVF not indicated: $120 • Cost/year of admissions when IVF not indicated: $43,800

  8. Results Continued • Total Number of Patients: 22 • Patients receiving maintenance IVF: 15/22 (68%) • Patients where maintenance IVF was indicated: 2/15 (13%) • Therefore, in approximately 87% maintenance IVF NOT indicated • Total L/day used in 13/15 (87%) of patients where IVF not indicated: 28.3L 2.2L/day per patient Please see supplementary information for table

  9. Results Continued • One bag of IVF is ~$10 • 2.2L/day per patient  $22/day/patient • Number of Medicine patients at time of study: 55 • 0.87*55: 48 • Extra cost for unnecessary maintenance IVF tx: 48 x $22/day: $1056/day • Cost per year: $385,440

  10. Costs Combined • Adding the costs from admission and maintenance IVF that are not indicated: • $43800 + $385440 = $429,240/year

  11. Study Limitations • Limited sample size • Patients limited to medicine service, therefore limiting generalization to other services • The percentage of meal consumption not determined (If not recorded in H&P/progress note, assumed patient with adequate po intake) • Differences in reimbursement methodology in various hospitals (?higher reimbursements with billing for IVF)

  12. Learning Points • Physicians in the Emergency Department as well as those in the Department of Internal Medicine should be educated about the indications for IVF • Patient charts should be reviewed daily to see if IVF indicated • Medical personnel should be made aware of the cumulative cost of IVF therapy

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