1996 OPEN FORUM Abstracts
PATIENT EVALUATION WITH A CONSULT SERVICE DECREASES THE FREQUENCY OF INAPPROPRIATE AEROSOL TREATMENTS
Karla Balasko RRT, Robert Chatburn RRT. University Hospitals of Cleveland, OH.
Evaluate and treat protocols have been shown to improve respiratory care resource utilization (Respir Care 1993;38:263-265). We developed a consult service that links objective evaluation of patient history and status to recommended treatment schedules (ie, aerosol, IPPB, airway clearance, incentive spirometry). The purpose of this study was to determine if the consult service decreases the frequency of inappropriate aerosol treatments and decreases cost of care compared to standard physician orders. METHOD: The consult service incorporates a patient history (ABGs, chest x-ray), clinical assessment (breath sounds, respiratory rate, cough, sputum production, work of breathing), and pulmonary function tests (peak flow, FEV1). Bronchodilator response is assessed by pre-and post-bronchodilator PFTs. A positive response is defined as greater than 15% increase in FEV1 or peak flow. Based on these data, one of two treatment plans is selected (MDI/wet neb either QID or Q4). Entry criteria were: adult patients with DRG code 79 (pneumonia), 127 (CHF), or 88 (COPD) with orders for aerosol treatments. Patient charts were reviewed randomly between 2/5/96 and 3/25/96. A treatment was judged appropriate if it met at least one criterion in each of two categories (1) Physiologic need: accessory muscle use, dyspnca, respiratory rate >30/min, wheezing, history of reversible airways disease; (2) Outcome: clearing of chest X-ray, >15% improvement PFT post bronchodilator, improved breath sounds. Respiratory care charting noted whether the aerosol order was under a consult or not. The proportion of appropriate versus non-appropriate treatments was compared for orders under consult versus non-consult using a Fisher Exact test. Significance was set at p=0.05. Cost calculations were based on variable supplies = $1.17, variable labor = $5.40, fixed indirect = $1.00, and treatment volume of 79,096 treatments/year. Results: A total of 542 aerosol treatments were reviewed. The raw data are shown in the figure below:
(See original for figure)
Overall, 15% of aerosol treatments were judged inappropriate. The total cost of inappropriate aerosol treatments is estimated to be $89,813/year. Comparing consult service vs non-consult service, there were less than half as many inappropriate treatments when the consult service was used (19% vs 9%, p < 0.001, odds ratio = 0.41). The potential cost savings of applying the current consult service to all aerosol orders is about $27,933/year. The associated potential labor time savings is 0.62 FTEs.
CONCLUSION: Systematic evaluation of physiologic need and clinical outcome decreases the frequency of inappropriate aerosol treatments. Because the department performs more than 79,000 aerosol treatments per year, a 40% reduction in inappropriate therapy (ie, from 15% to 9%) by universal application of the consult service would represent a significant savings in cost and labor hours. We are currently trying to improve the discrimination ability of the consult service to achieve further reductions.