Cost-Containment Project: “Just a Liter of Normal

Saline”

Mohammad Usman Qazi, PGY2Department of Internal Medicine

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

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

Indications for IVF:• Indications for the prescription of intravenous fluids

I. Highest prioritya) 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

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

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

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

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

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

Costs Combined

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

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)

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