Hospital Obstruction: Reduced Throughput and Increased Cost Associated with Discharge from Step‐Down Units

Background:

Step‐down units, also known as transitional care or intermediate care units, are designed to care for patients with needs that fall between the intensive care unit and the general ward. Such units are capable of providing highly skilled care, primarily due to a lower patient to nurse ratio, and are often in significant demand from the ER and ICU. While patient throughput in the ER has been a subject of significant study, little has been written on moving patients efficiently from higher‐acuity to lower‐acuity units during the course of their hospitalization. The purpose of this study was to describe the use of step‐down level care at a large academic medical center.

Methods:

There are three step‐down units at our hospital and typical capabilities include q2 hour vital sign checks, IV cardiac medication administration and NIPPV. Using our hospital’s administrative data, we determined that the cost difference between a step‐down bed and a floor bed is approximately $500 per day and the difference between an ICU bed and a step‐down bed is approximately $1600 per day. We conducted a retrospective chart review of all patients admitted or transferred to step‐down units during the 2012‐2013 academic year. Data was abstracted from the electronic medical record and we used descriptive statistical methods to describe the use of step‐down units at our hospital.

Results:

During the 2012‐2013 academic year, 3,084 patients were admitted to one of three step‐down units at some point during their hospitalization (Table 1). 51.2% of those patients were admitted to the hospital medicine service with the rest admitted to various subspecialty services. Of all the patients admitted to a step‐down unit during their hospitalization, 80.0% were discharged to home or skilled nursing facility from a step‐down unit. On hospital medicine, 83.9% were discharged from a step‐down unit. Given our high percentage of discharges from step‐down units, we projected the cost‐savings of moving 20% of our patients from step‐down to the lower‐acuity ward one day prior to discharge. Neglecting the potential upstream cost‐savings from moving a patient out of the ICU or ER, this improved throughput could save $292,300 dollars over the course of a year.

Conclusions:

This study demonstrates that patients at our hospital who are admitted or transferred to a step‐down unit are overwhelmingly more likely to be discharged from this higher‐acuity unit than to transfer to a lower‐acuity unit prior to discharge. Interventions aimed at increasing such transfers has the potential to improve hospital throughput and generate a significant cost‐savings.