Intensive care unit procedures: cost savings and patient safety

Introduction

Intensive Care unit (ICU) management of critically ill patients often includes the requirement for tracheostomy and feeding access, most often a pecutaneous endoscopic gastrostomy (PEG). Although advances in ICU airway management include percutaneous tracheostomy, semi-open tracheostomy and conventional tracheostomy, the majority of critically ill surgical and injured patients still receive open tracheostomy in the Operating Room at Duke University Medical Center (DUMC). Although percutaneous tracheostomy is performed routinely in many medical ICU settings, in high risk surgical and trauma patients who often have unstable cervical spine injury and tissue edema, direct visualization of the cervical structures and trachea is imperative during tracheostomy. We have undertaken open tracheostomy and PEG in the ICU in selected patients as part of a collaborative, multidisciplinary ICU patient management strategy at DUMC. This initiative has been undertaken to address the risk of patient transport, the inappropriate use of OR time, and the cost to the patient as part of an effort to standardize and improve patient care.

Methods

After informed consent, utilizing DUMC conscious sedation protocol, full ICU monitoring, and sterile OR technique,13 tracheostomies and 8 PEG placements were performed in 13 patients in the ICU since July, 1998. There were no complications. Operating Room costs include basic room fee and charge per minute for general surgery and anesthesia and the anesthesia professional fee. Surgical professional fee, tracheostomy tube cost, and gastroscope maintenance are identical and not included in the analysis. ICU costs include gowns, gloves, drapes and tracheostomy tray. For purposes of analysis, OR tracheostomy and OR PEG times were defined as 120 min and 60 min respectively; although analysis of fiscal year 1997-1998 yield widely divergent average OR times for these procedures.

Results

A table of cost comparison for individual procedure, total to date and associated cost savings are shown below.

Conclusion

Tracheostomy and PEG placement in the ICU in selected patients are safe, avoid patient travel, improve OR utilization and show a significant reduction in cost.

Table 1