Continuous intravenous infusions – or “drips” – can be burdensome for patients and clinicians. With this in mind, we identified three scenarios for which providers could safely “skip the drip” in favor a therapeutic alternative: 1) continuous proton pump inhibitor (PPI) infusions for patients with gastrointestinal bleeding; 2) continuous intravenous diuretic therapy in congestive heart failure; and 3) sodium bicarbonate drips in lactic acidosis.
To work in a collaborative, multi-disciplinary approach to achieve higher value for patients, where value is defined as quality delivered for a given cost.
Our quality improvement initiative was submitted by 2 residents to the hospital’s “Choosing Wisely” challenge. The intervention mapped to the COST Framework: Culture, Oversight, Systems change, and Training. We sought to impact our institution’s culture by recruiting faculty subspecialty champions in the sections of cardiology, nephroloy, gastroenterology, emergency medicine, hospital medicine, and pulmonary/critical care. Each champion discussed our proposal with their colleagues via email or in person. We maintained oversight via bi-weekly review of providers’ orders. We changed our systems via electronic health record (EHR) modifications to summarize data regarding proper indications for these continuous infusions and to ask providers to choose an exception if they still wish to order an infusion. Finally, we implemented training, in-person and via email, of medicine and emergency department house-staff and hospitalists.
To date, we focus on appropriateness of continuous PPI orders in the three months post-intervention, compared to three-month historical control period pre-implementation. Time-driven activity-based costing (TDABC) was used to calculate cost savings based on US Department of Labor wages for nursing and pharmacy.
The number of PPI drips post-intervention was 53, compared to 60 pre-intervention. Specifically, post-endoscopic PPI continuous IV therapy was appropriately discontinued at a significantly greater rate post-intervention (from 66% to 93%, p=0.004). The choice of post-endoscopy PPI was also more likely to follow established guidelines (83% vs. 95%, p=.09). Using TDABC, we calculated a $277.45 difference in cost per patient day for using continuous PPI infusion vs. twice-daily PPI, with potential for saving over $93,000 per year based on preliminary data.
A house-staff led quality improvement project led to improvement in appropriate use of PPI continuous infusions. More work remains to more sustain this intervention, and to study utilization of bicarbonate and diuretic infusions.