A Strategy for Inpatient Integration Terry Horton, MD, FACP Delaware Valley Node September 21, 2010.
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Transcript of A Strategy for Inpatient Integration Terry Horton, MD, FACP Delaware Valley Node September 21, 2010.
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A Strategy for Inpatient Integration
Terry Horton, MD, FACPDelaware Valley NodeSeptember 21, 2010
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Hospitals Inpatient Services Aggregate the Highly Disordered
Much higher rates of AUD and SA compared to general society, most are dependent*
Significant medical comorbidities Expensive revolving door
higher use of ER (2.3x), inpatient care (6.7x)** Increased AMA, readmissions
* Saitz, 2007; Bertholet, 2010** Stein, 1993
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Hospitals have an Emerging Imperative
Need to Improve: Safety Health care costs Joint Commission
compliance
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Hospitals Need Best Methods/tools to:
Screen and diagnose – must be pragmatic Effectively treat withdrawal Engage and transition into ongoing drug tx
SBIRT not effective for inpatients but Linkage to tx improves outcome*
* Bertholet, 2010
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Delaware’s Epidemiology
Estimated 2009 population of 885,000 9% of adults alcohol/drug abusing or
dependent* 65,000 in need of alcohol/drug treatment** 8,216 admissions to publicly-funded SA
treatment services statewide 2006***
* 2004-2005 NSDUH data** Wright et al. 2007*** Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health, 2007
Tx gap
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Delaware’s Primary Hospital System
• Wilmington/Christiana Hospitals
• 1100 beds
• 160,491 ER visits
• 54,597 admissions*
• No in-house substance abuse/etoh service
*2009 data
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CCHS prior to 2009
No standardized ETOH/Substance abuse screening SBIRT for trauma service only
No standardized withdrawal treatment protocols or monitoring
Social Work consult for referral 3 root cause analyses in 2007-8 directly
related to delirium and tremens
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2008-9 CCHS Epidemiology
Less than expected rates of ETOH withdrawal
( 0.75% actual vs. 0.9-1.25% calc) 2x more DTs than expected
(0.2% vs. 0.05-.125%) Majority of DTs are secondary dx’s
115/179 (64%) 1/1/08-7/31/09 23% >= 65 years old
Deaths more common in secondary dx: 19/20
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The Intervention
ETOH Withdrawal Symptom Order Set launched on October 6, 2009 for med/surg inpatients includes screening tool for risk of AW CIWA clinical assessment/scoring Score triggered treatment and monitoring
protocol
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Outcomes: Improved Safety
No Sentinel Events since launch Significant reduction of submitted
cases to DOM No cases to date associated with over-
treatment
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Quarterly Outcomes Data
Secondary Diagnoses Summary
28 22 27 29
12 16
0
20
40
60
80
100
1Q09 2Q09 3Q09 4Q09 1Q10 2Q10
Quarters
Num
ber o
f Pat
ient
s
Sec DX of AW
Sec DX of DT
Protocol launch
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Restraints Use
Percentage of AW and DT Patients with Restraint
0
20
40
60
80
AW DT
Diagnosis
Perc
en
tag
e
Pre
Post
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ICU Transfers
Percentage of AW and DT patients Transferred from Floor to ICU
0
5
10
15
20
25
AW DT
Diagnosis
Per
cent
age
Pre
Post
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Length of Stay
Delirium Tremens DiagnosisALOS
8.93 9.89
15.4313.48
7.5010.34
0
5
10
15
20
Q1'09 Q2'09 Q3'09 Q4'09 Q1'10 Q2'10
Day
s
Protocol launch
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Project Engagement
Community partner imbedded at WH Peer-to-peer inpt/outpt intervention Data Review
N = 313 (9/1/08- 6/10/10) 35% successfully admitted into 33 inpt/out
drug/alcohol treatment programs
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Project Engagement: Partnering with DPCI/Aetna
Claims from June 1, 2009 - November 30, 2009 3 months before and after claims review, n = 18
Metric Pre Post Finding
Medical inpatient admits 12 8 33% decrease
ER visits 54 33 38% decrease
BH/SA inpatient admits 7 10 43% increase
BH/SA outpatient visits 12 16 33% increase
PCP office visits 27 51 88% increase
Delaware Physicians Care Inc, May, 2010
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CTN Opportunities for Inpatient-based Research
Define/develop pragmatic tools and protocols to screen and improve safety
Develop and test methods to engagement and link into ongoing drug/etoh treatment
Study clinical and fiscal outcomes