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Cost-Containment Project: “Just a Liter of Normal
Saline”
Mohammad Usman Qazi, PGY2Department of Internal Medicine
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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
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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
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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
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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
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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
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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
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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
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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
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Costs Combined
• Adding the costs from admission and maintenance IVF that are not indicated:– $43800 + $385440 = $429,240/year
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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)
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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