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Seeing more patients? Your costs will rise

May 2014

Published in the May 2014 issue of Today’s Hospitalist.

Seeing more patients? Your costs will rise

WHILE HOSPITALISTS face increasing pressure to improve productivity, daily workloads above 15 encounters result in longer lengths of stay and higher costs. That’s the conclusion of a study posted online in March by JAMA Internal Medicine that looked at the impact of increased numbers of hospitalist encounters and wRVUs.

The authors analyzed more than 20,000 admissions in two Christiana Care Health System hospitals in Delaware. They found that when hospitalists had more than 15 patient encounters per shift, length of stay grew by as much as two days and hospital costs rose between $5,000 and $7,500 per patient. The study found that workload changes did not affect mortality or readmission rates or patient satisfaction scores.

A related editorial pointed out that the study could have important financial implications for hospitalist groups. Because most programs receive hospital subsidies, the data support “maintaining a manageable census” as a good investment that can improve not only bed availability, but physician retention.

SGR patch delays ICD-10, two-midnight rule

IN MARCH, Congress once again passed a last-minute reprieve of the sustainable growth rate (SGR), heading off a 24% cut in Medicare reimbursements to physicians and replacing it with a 0.5% update through the end of this year.

However, the bill “which was signed into law “caught administrators and providers off guard by also including delays in enforcing the two-midnight rule for inpatient admissions and the implementation of ICD-10. According to the new law, enforcement of the two-midnight rule will be delayed until after March 31, 2015, while ICD-10 implementation will be put off until at least Oct. 1, 2015. At press time, the Centers for Medicare and Medicaid Services (CMS) had not set any definite date for ICD-10 implementation.

According to MedPage Today coverage, the ICD-10 delay represents enormous costs for hospitals in terms of recruiting and training new coding staff who must now be retrained, as well as upgrading computer systems and buying training software. The CMS estimates that every year that ICD-10 implementation is delayed costs the health care industry between $1 billion and $6 billion.

Should sepsis protocols be revisited?

A FIVE-YEAR STUDY looking at a widely-accepted sepsis protocol concludes that some of that bundle’s most expensive and risky components don’t improve patient outcomes.

The study, which was posted online by the New England Journal of Medicine in March, assigned sepsis patients presenting to one of 31 U.S. EDs to receive either protocol-based early goal-directed therapy, protocol-based standard therapy or usual care. While patients in those three arms had varying rates of 60-day mortality (21%, 18.2% and 18.9%), those differences weren’t statistically significant. That was also the case for differences in 90-day and one-year mortality rates.

The study didn’t challenge early sepsis identification or early administration of antibiotics and fluids. However, it did not support the use of “central venous catheterization or central hemodynamic monitoring in all patients,” the authors wrote. The National Quality Forum and the International Surviving Sepsis Campaign have endorsed a six-hour bundle that includes catheterization and monitoring.

Timing and tissue with tPA

SMALL DELAYS in administering IV tPA can add up to big health deficits for patients with acute ischemic stroke.

A study posted online in March by Stroke finds that every minute sooner between onset and treatment that patients receive IV thrombolysis translates to on average nearly two additional disability-free days over the course of a lifetime, with one month free of disability for every 15 minutes sooner IV tPA is administered. While the effect was observed across all age groups, researchers found that younger patients derived more benefits from earlier treatment.

Researchers modeled data from more than 2,200 patients who received IV tPA in Australia and Finland between 1998 and 2011. The authors noted that many centers around the world are now able to administer IV tPA in less than 30 minutes between presentation and treatment. They pointed out, however, that treatment delays between the best centers and average facilities can be as long as 60 minutes.

Mixed results with RRT alerts

A NEW STUDY looking at the impact of sending real-time alerts to rapid response team (RRT) personnel found that the use of alerts modestly reduced patients’ length of stay. It did not, however, lower their number of ICU transfers or the rate of in-hospital mortality.

Researchers relied on an early warning system to identify deteriorating patients on medicine wards in one academic center. Some identified patients were randomized to have real-time alerts sent to the RRT, while others received usual care.

The median length of stay for patients for whom the RRT was contacted in real time was 4.5 days vs. a median of 5.3 days for controls. However, both groups had similar transfer rates to an ICU or nursing home. They also had similar readmission and mortality rates.

Authors did note that communication between the RRT and the primary care team was enhanced in the intervention arm, and that intervention patients also received more telemetry and oximetry than controls. The study was published online in April by the Journal of Hospital Medicine.

Experienced nurses deliver big benefits

WANT TO LOWER hospital costs and reduce length of stay? Hold on to your nurses. According to a new study, every one-year increase in the hospital tenure of RNs was associated with a 1.3% decrease in patients’ length of stay.

Published in April by the American Economics Journal: Applied Economics, the study is the largest to date to link nursing experience to patient outcomes. Researchers looked at 900,000 VA admissions over four years, as well as payroll data for nursing staff, to examine how staffing changes affected length of stay.

Researchers found an association between adding new RNs or losing experienced nurses and increased lengths of stay. Study results also indicated that length of stay was lower when staff RNs were paid overtime vs. hiring temporary nurses to fill vacancies. As a result, the study concluded, overtime can be more cost effective than temporary staff.

Length of stay was also lower for patients treated by RNs than by unlicensed nursing assistants.

Hospitals start posting their own reviews

WHEN DOCTORS with University of Utah Health Care in Salt Lake City read some bad online reviews of themselves, they convinced their health care system to post their patient satisfaction scores and comments.

The hospital’s online review page now allows patients to search through Press Ganey scores and comments from surveyed patients, according to Kaiser Health News. While all the doctors received either four or five stars, survey results posted do include some negative patient comments.

The article noted that Cleveland Clinic is considering a similar move, while Integris Health, the largest hospital system in Oklahoma, planned to start posting online consumer satisfaction scores on 70 of its physicians by the end of last month.

Sources in the article pointed out that health systems that primarily employ physicians may follow suit, but that those staffed with a greater number of independent doctors probably would not, for fear of antagonizing those physicians.

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