A decade ago, chest pain units swept the nation as a strategy to improve patient outcomes and decrease costs for the treatment of acute coronary syndromes. A similar trend is now occurring for the Observation Unit management of HF.
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In 2002, an observation billing code was established for Heart Failure, Chest Pain, and Asthma. The requirements for the code are very easy to meet. All it takes to get this code is a pulse ox, an EKG, and a chest x-ray, all basic tests for patients presenting with suspected heart failure. The only other requirement is that patients must remain in observation for at least 8 hours. They may stay up to 48 hours, but you only get paid up to 24 hours. So most places make an admission/discharge decision at the 24-hour point.
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Another benefit to the code is that the cost of tests is billed as a pass through rather than as part of your DRG as happens with inpatient care. Therefore every BNP test, for example, given in the ED will actually make the hospital a margin of $20 or so. As far as drug cost, nesiritide, which costs about $380 per vial, is reimbursed at $433 by the DRG, which means that the hospital takes a margin of $53 every time it is ordered.
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The takeaway is that the government is encouraging observation management of heart failure, chest pain, and asthma, and is making treatment for these diagnoses a financially viable proposition.
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Now I'd like to share our own center's ED heart failure protocol. Our ED opened in 1994 with a 20-bed Observation Unit attached. In 2002 we had 3,162 admissions to the Observation Unit. The criteria for admission to the Obs Unit is for the patient to have a 75% chance of going home within 24 hours. Our average length of stay is 17 hours.
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It is important to understand that patients enrolled in our Obs Unit are relatively stable. For example, they are not the patients who get IV nitroglycerin. In our center, patients on IV nitro have to go to the ICU.
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We don't care what the diagnosis is for these patients; we'll put almost anybody in the Obs Unit as long as they are relatively stable and we think we can get them out by the next day.
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We do have a heart failure protocol. The patient needs something from their history and their physical that points to heart failure, as well as positive test results, including an elevated BNP.
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Patients are excluded from the protocol if they require dialysis, have an elevated temperature, have pneumonia, have a peak flow of less than 50% of predicted along with wheezing, require an IV vasoactive medication (other than nesiritide), have a clinically significant arrhythmia, have an ECG with diagnostic criteria for acute MI or ischemia, or have abnormal cardiac markers.
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The protocol has a diuretic algorithm that states the patient must urinate 500 cc's in the first 2 hours, and if not, the dose of Lasix is doubled. If the patient's creatinine is greater than 2, then the criteria is halved to 250 cc's in the first 2 hours. There is also an ACE inhibitor algorithm, though we are using more nesiritide than ACE inhibitors now. The entire protocol is administered by nurses. Everything is automatic and by the book.
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Each patient gets a rule-out for MI and an echocardiogram if it's been more than a year since their last one and they don't already have known systolic HF. Patients also watch an educational video, get dietary counseling if needed, and have a consult with an HF physician with whom they will follow up after discharge.
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Our discharge criteria are that patients "ambulate, mentate, and urinate (walk, talk, and pee)." They have to have decent vital signs and stable labs.
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To assess the effect of our heart failure protocol we looked at returns to the hospital and mortality at 90 days post discharge. As we can see here, before the institution of the protocol we saw that 90% of patients came back to the ED within 90 days. This dropped to 51% after the protocol went into effect. Similarly, rehospitalizations dropped from 77% to 50% with the protocol, and deaths within 90 days fell from 4% to 1%.
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For patients who failed the protocol and had to be admitted to the hospital, we see that total length of stay is reduced by 23%.
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Another phenomenon we have seen is that, because we are helping the least-sick patients avoid admission, the acuity of the conditions for patients who do get admitted increases. One result of this is that the more-acute conditions are associated with more billable procedures, such as cardioversion, catheterization, transfusions, ART lines, etc, which helps the bottom line for the institution.
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By reducing overall costs through avoiding admissions, we were able to save our hospital almost $100,000 in 1997 dollars with the HF protocol.
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In selected patients, the Observation Unit provides the opportunity of decreased hospitalizations, less time in the hospital if admitted, and lower rates of revisits, all at a lower cost to the institution.
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Welcome to our program on Acute Heart Failure: The Emergency Department and the Economics of Care. This is a CME-accredited program that focuses on optimizing treatment strategies in the Emergency Department in order to improve outcomes and reduce overall costs to the hospital.
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When you think about the overall hospital costs of a 5-day admission for an acute condition that often requires ICU care and invasive procedures, you don't necessarily think about the Emergency Department. After all, the patient is usually only in the ED for a few short hours, compared to the several days they will spend as an inpatient. But when it comes to treating acute heart failure, we are beginning to learn that what occurs during those critical initial hours in the Emergency Department has a direct and significant impact on overall treatment outcomes, including the length of stay as an inpatient, the utilization of expensive resources, and the likelihood of readmission to the hospital within the near term.
