1. Cost-Containment Project: “Just a Liter of Normal Saline” Part II William Graham, PGY2

2. 2 Project Goal -One-year follow-up into the prescribing of intravenous fluid therapy in patients at time of admission and for maintenance fluids - 75% of patients receiving IVF at time of admission have no indication for IVF (12 of 16 pts) - 87% of patients receiving maintenance IVF have no indication (13/15) -Calculate current costs of IVF therapy in cases where it is not indicated (admission and maintenance) - At ~$10/bag if IVF, resulted in cost of ~$43,800/year in unnecessary expense on IVF at time of admission - ~$385K spent in maintenance IVF without indication -Identify means of improved adherence to guidelines Department of Medicine| January 2014

3. 3 Indications for 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., anesthesia) b) Return the ICF volume towards normal 1. Acute hypernatremia that is symptomatic 2. Chronic hypernatremia with a seizure 3. Chronic asymptomatic hypernatremia II. Moderate priority a) Re-expand a modestly contracted ECF volume b) Replace ongoing losses c) Avoid oliguria d) 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 Department of Medicine| January 2014

4. 4 Study Sample -Replicated study design from 2012 investigation to comparatively evaluate -Inclusion Criteria: - Admission to Med/Surg or Telemetry floors from ED or transferred from ICU -Exclusion Criteria: - Outside Hospital transfers - Patients admitted with shock (septic, cardiogenic, hemorrhagic) -Random selection of 29 participants from patients (72 total; 55 last year) currently on 6 medicine services at UCIMC based on above inclusion/exclusion criteria Department of Medicine| January 2014

5. 5 Study Methods -“Guideline concordant” IVF indications at time of admission: - Severe Sepsis - HD instability (evidenced by HR > 90 or SBP < 90 in setting of presumed sepsis, hemorrhage or fluid depletion) - Fluid resuscitation (diarrhea, vomiting, pancreatitis, AKI, DKA) - Burns -“Guideline concordant” indications for maintenance IVF: - Patient NPO - Patient with poor nutritional intake - Correction of electrolyte abnormalities (hyper/hyponatremia) - Oliguria/AKI Department of Medicine| January 2014

6. 6 Study Methods -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 liters of IVF given on admission where not indicated  cost per admission calculated -Liters of maintenance IVF used per day recorded in patients where IVF not indicated  cost per day calculated for % of patients where IVF not indicated Department of Medicine| January 2014

7. 7 Results Number of Patients: 29 Patients given IVF on Admission: 21/29 (16/22) Patients where IVF was indicated on Admission: 15/21 (71%) (25%) Total Liters of fluids given on admission to 15 patients where they were not indicated: 8.0L Avg L/admission: 0.53 L (1.6 L) Avg cost of 1L Bag of IVF: $10 Cost/admission to medicine: $5.33/admission Average # of admissions to medicine/day: 10 (29% with no indication for IVF) Cost/day of admissions when IVF not indicated: $15.33 Cost/year of admissions when IVF not indicated: $5,595.45 _________________________________________________ Difference from last year: $43,800 - $5,595.45 = $38,204! Department of Medicine| January 2014

8. 8 Results Total Number of Patients: 29 Patients receiving maintenance IVF: 23/29 (79%) (68%) Patients where maintenance IVF was indicated: 15/23 (65%) (13%) Therefore, approximately 50% improvement in one year Total L/day used in 8/23 (35%) of patients where IVF not indicated: 19.2L  2.4L/day/patient (2.2 L/day/patient) Department of Medicine| January 2014

9. 9 Results One bag of IVF is ~$10 2.4L/day per patient  $24/day/patient Number of Medicine patients at time of study: 72 (55) 0.35 x 72 = 25.2 Extra cost for unnecessary maintenance IVF tx: 25.2 x $24/day= $605/day Cost per year: $220,752 Difference from last year: $385,440 – $220,752 = $164,688! Department of Medicine| January 2014

10. 10 Results 2012 costs from admission and maintenance IVF that were not indicated: $43800 + $385440 = $429,240/year 2013 costs from admission and maintenance IVF that were not indicated: $5595 + $220752 = $226,347/year Year-to-year cost savings: $429,240 - $226,347 = $202,893/year! Department of Medicine| January 2014

11. 11 Study Limitations -Limited sample size -Patients limited to medicine service -Variability in IVF costs to hospitals/patients -Differences in reimbursement methodology in various hospitals (? higher reimbursements with billing for IVF)

12. 12 Learning Points Improvement in physician ordering habits in both the ED and medicine floors through education can result in substantial cost reductions. Patient charts should be reviewed daily to see if IVF indicated Importance of considering the indications of IVF should be reiterated annually as new interns and trainees arrive Medical personnel should be made aware of the cumulative cost of IVF therapy