Abstract 247: Reducing Costs and Intensive Care Unit Length of Stay in Patients with Intracerebral Hemorrhage

Abstract

Background/Objectives: Intravenous (IV) antihypertensive infusions are often used acutely in patients with intracerebral hemorrhage (ICH). However, they are often administered inconsistently with current guidelines, and are associated with increased length of stay (LOS) and nosocomial morbidity. They are also more expensive than oral formulations and typically necessitate care in the intensive care unit (ICU), further increasing cost and morbidity. We examined the use of antihypertensive infusions in ICH patients in our institution, characterized their impact on cost and LOS, and developed an intervention grounded in quality improvement methodology to reduce the cost and LOS of ICH patients. Methods: Patients were included if they had been admitted to our comprehensive stroke center with an ICD-10 diagnosis of non-traumatic ICH from September 2017-2018. LOS and cost data were obtained from Vizient. IV antihypertensive use was extracted via retrospective chart review. We also collected data on quality metrics guided by focus group discussions with key stakeholders. Results: Eighty-one ICH patients over a 12-month period were reviewed. Fifty-nine patients (73%) received IV antihypertensive infusions. In patients who received infusions versus those who did not, mean total LOS (8.4 vs. 4.1 days, p=0.001) and total direct cost of stay ($44115 vs. $17249, p<0.001) were increased. Mean duration of infusion was 51 hours; 54% of patients received <2 IV antihypertensive boluses during the infusion to facilitate weaning, and 40% of patients were not started on oral antihypertensives on their first day with enteral access. Documented blood pressure goals were discordant with medication order parameters in 59% of patients. Root cause analysis (Figure 1) led to implementation of interventions focused on key drivers of consistent communication, concordant documentation, adequate medication availability, and consistent enteral option utilization. Conclusions: ICH patients requiring antihypertensive infusions had significantly higher direct costs and increased LOS. Root-cause analysis identified targets to improve quality of ICH care, leading to the development of formal interventions to facilitate transition from IV to oral antihypertensives. Post-intervention data will be available April 2019.