Parenteral antibiotic use in acute-care hospitals: A standardized analysis of fourteen institutions.

Despite increasing concerns regarding the need to optimize appropriate antibiotic use in hospitals, a standardized method for evaluating interinstitutional antibiotic use has not been developed. To address this issue, antibiotic use was analyzed by means of a uniform methodology among 14 acute-care hospitals. Data were standardized by use of a defined daily dose for each antibiotic while adjusting for patient volume by calculating use per 1000 patient-days. Within the group, there was a 68% range in total parenteral antibiotic expenditures and wide variability in the use of individual agents. Analysis of these differences indicated that only the use of active antibiotic-management programs clearly correlated with antibiotic cost per 1000 patient-days (P<.001). Given these results, we believe that wider comparative analysis of antibiotic use with a standardized methodology in conjunction with standardized analysis of nosocomial infection rates and antibiotic resistance data may enhance the stewardship of antibiotics in acute-care hospitals.

Relationship between practice characteristics of primary care internists and unnecessary hospital days.

BACKGROUND: Inpatient utilization review remains a useful approach for hospitals to achieve cost savings, however utilization review efforts need to become more focused and sophisticated. METHODS: In order to identify physicians with a higher percentage of unnecessary hospital days, and to analyze how their practice characteristics distinguished them from their colleagues, 364 consecutive admissions of 57 primary care internists were reviewed concurrently, on a daily basis. Days without acute hospital level of care that occurred while patients were awaiting placement in a rehabilitation or in a chronic care facility were adjusted out of the calculation. Analysis was undertaken to assess the impact of physician age, location of training, Board Certification, practice location, participation in medical training programs, years of experience, and participation in various types of managed-care programs on the level of unnecessary hospital days. Characteristics of the patients and their illnesses were included in the analysis. RESULTS: A large number of unnecessary hospital days occurred although there was no useful segregation of good from poor physician utilizers. Board certification and suburban practice location were associated with a significantly lower percentage of adjusted unnecessary days. Physician members of a closed-panel health maintenance organization had a lower percentage of adjusted unnecessary hospital days (14% vs. 41%, P < .001) when compared with the other primary care internists. Explanations for the difference are discussed. CONCLUSIONS: 1) The patients of primary care internists are still responsible for a large number of unnecessary hospital days; 2) Utilization review efforts need to become more sophisticated and focused; and 3) A change in physician incentives coupled with appropriate staff and systems possibly would be the simplest, large-scale remedy.

Enhanced length of stay management through monitoring of discharge planning parameters.

Traditional data collection in discharge planning programs has been largely retrospective, measuring the patient's length of stay and unnecessary hospital days at the point of discharge. Although the data collection is useful, it does not lend itself to corrective actions on a concurrent basis. Carney Hospital has developed a data base that monitors patient status daily in order to identify when a length of stay problem is developing and when corrective actions are succeeding. The Patient Tracking System is an interactive computer report utilized by Continuing Care staff, Utilization Review staff, and clinical managers on the patient care units. It is a caseload register that operates from the admission transfer discharge (A/T/D) system of the hospital and sorts inpatients by discharge planning status, length of stay, discharge planning worker, and nursing unit. It is the basis for a weekly management review that identifies numbers of patients and average length of stay to date of key groups of patients proven to impact the overall length of stay in the hospital. Carney Hospital has successfully utilized this system to alert managers to any length of stay "creep," to identify the sources of the length-of-stay problem, and to mobilize key personnel to take corrective actions. The system is easy to use and is an effective length-of-stay management tool.

The UR hot line: purpose and process.

Institutions embarking on utilization endeavors require mechanisms to identify and quantitate institution-specific problems. This article describes, with examples, the application of a utilization hot line as a cost-effective tool to focus efforts and solve immediate problems.

This OWL (outpatient work-up liaison) would not fly. Environmental factors foil attempt to shift unnecessary inpatient days to the outpatient setting.

The last days of many appropriate hospital admissions have been identified as unnecessary when utilized for providing diagnostic or therapeutic modalities that could be provided in an outpatient setting. An outpatient work-up liaison team (OWL) was established to facilitate the completion of evaluations or therapy in the community. In spite of the commitment of experienced personnel and the cooperation of the staff physicians and hospital departments, the effort was unsuccessful. The failure is attributed to the socioeconomic environment in the immediate community that could not support the transfer of medical efforts. It is recommended that before any institution undertakes shifting hospital-based services to the community a realistic assessment be made of the socioeconomic milieu.

Formatting departmental quality assurance minutes to meet internal and external needs.

This article presents a method that is helpful in achieving compliance with the JCAHO medical staff monitoring standards. Since the QA activity of the medical staff is of great importance to the institution, it is imperative that monitoring activities are clearly documented and easily evaluated. Through the use of a standardized departmental minutes format, each clinical department is prompted to address the monthly activity relating to each of the basic quality assurance functions. These minutes can be "scored" using an evaluation tool suitable for review by the Medical Executive Committee. This enables the committee to track the status of each department's use of the "Ten Step Process." This method has successfully met the challenge of a recent JCAHO accreditation visit. The use of the standardized departmental minutes format and the evaluation tool provide a method to successfully meet the JCAHO medical staff quality assurance standards.

Comparison of efficiency of cardiologists and internists in managing patients with suspected myocardial chest pain.

The charts of 56 patients with chest pain who were admitted to the critical care units to rule out myocardial infarction were evaluated concurrently and retrospectively to compare the efficiency of cardiologists and internists. The number of unnecessary days used to rule out myocardial infarction, the number of unnecessary inhospital days used after ruling out myocardial infarction, the length of cardiac work-up, and the length of hospital stay were determined for 23 patients of cardiologists and 33 patients of internists. The cardiologists' patients had fewer unnecessary days after ruling out myocardial infarction (2.76 vs. 0.43 days, p less than .01) and a shorter length of hospital stay (5.15 vs. 2.91 days, p less than .02). We concluded that consideration should be given to increasing and refining the supplementary role of physician-experts to primary care physicians as one means of improved resource allocation.

Overutilization of serum electrolyte determinations in critical care units. Savings may be more apparent than real but what is real is of increasing importance.

Electrolyte (E) utilization by medical and surgical house staff in the critical care units of a community teaching hospital was audited over a two-month period. One hundred forty-five patients involved in 708 patient days had 924 sets of electrolytes (SE). Of the 581 SE that were ordered as an additional set within 24 h, 10% were considered unnecessary and 65% could have had a single E substituted for the complete set. The conclusion of this study and literature review are: (1) Electrolytes are excessively ordered in the management of critical care patients. (2) When additional electrolyte data is required within 24 h, a single electrolyte will usually suffice. (3) Misutilization is equally prevalent among medical house staff and surgical house staff. (4) The cost savings to be realized from improved laboratory utilization are only a small percentage of the potential savings in charges. (5) No single, proven modality has been identified which will consistently, continually, and appropriately decrease laboratory overutilization.