Cost of Oral Contrast in ED Patients with Non-traumatic Abdominal Pain Final Report April 17th, 2018 Emily Herbstman, Trevor Hoffman, Alexis Flake, Ben Sweeney Team 5 . . . Dr. Prasad Shankar, Assistant Professor of Radiology Dr. Matthew Davenport, Associate Professor of Radiology and Urology Ms. Allie Mukavitz, Industrial Engineering Fellow Mr. Jonathan Lee, Industrial Engineer Dr. Mark Van Oyen, IOE 481 Professor 18W5-final-presentation

Introduction and Background IV contrast vs oral contrast Readi-Cat and Gastrografin Policy change on June 1st, 2017 Exceptions: BMI under 25, recent abdominal surgery, pre-existing inflammatory bowel disease Oral contrast takes hours and has an impact on ED workflow Scan with oral contrast shows anatomy of abdomen

Key Issues Increased time of patient in a bed Delays in Emergency Department Workflow

Goals and Objectives Design a process map of oral contrast administration Find the average time range necessary for ED staff to complete oral contrast administration Calculate the labor, materials, and time costs incurred from the oral contrast administration process

Project Scope Patients receiving CT scans outside of the ED Non-traumatic abdominal pain patients receiving CT scans in the ED Patients receiving oral contrast Time from when the CT scan is ordered to when patient leaves for scan Cost of labor, cost of material, time, occupancy Patients receiving CT scans outside of the ED Patients receiving no form of contrast Any diagnosis, follow-ups, or additional testing

Approach Literature Review Time Studies Informal Interviews 1 Literature Review Time Studies 2 Approach 3 Informal Interviews 4 Cost Calculation 5 Retrospective Data Analysis

Literature Review Significant time difference between oral contrast and IV patients Mean time for oral contrast procedure of 105.5 minutes and no diagnostic compromise for appendicitis patients who did not receive oral contrast Oral contrast not required to establish diagnosis for patients in ED with non-traumatic abdominal pain Time-Driven Activity-Based-Costing (TDABC) to calculate labor costs

Time Studies February 5th - March 30th Identified steps for process map 100 hours of observation Found average times for each process step

Informal Interviews Low volume of oral contrast patients Strengthened sense of processes Time estimates

Labor Costing TDABC formula Salary Data from Bureau of Labor Statistics Staff utilization, salary, and benefits considered

Material Costing Readi-Cat: 10 distributors $3.32 per patient Gastrogafin: 7 distributors $13.70 per patient

Occupancy Costing Drinking times for Readi-Cat and Gastrografin take 57, 93 minutes, respectively Real & opportunity costs associated with time spent in a bed A literature search was conducted determining a cost range of $.10/minute-$1.41/min for time spent in ED bed Used $.21/min from radiologists expert opinion

Retrospective Data Analysis

Findings: Time Studies Contrast Preparation Dose 1 Administration Dose 1 Progress Check Dose 2 Administration Dose 2 Progress Check 3:41* 2:48 2:39 2:24 2:45 * Add 90 seconds to contrast preparation for Gastrografin

Findings: Per Patient Costs Contrast Type Labor Cost Material Cost Occupancy Cost Total Cost Readi-Cat $12.01 $3.41 $12.03 $27.45 Gastrografin $13.73 $16.05 $19.58 $49.36

Findings: Total ED Cost Savings Total cost of $150,570 over the year ~$94,000 attributed to Readi-Cat (3,391 patients) ~$57,000 attributed gastrografin (1,150) Using BMI, IBD, Surgery criteria, 2,648 patients would no longer receive contrast. $86,814 in cost reduction when removing these patients → annual ED savings

Findings: Process

Design Methods: Process Map Different Roles Different Contrast Types Step Granularity Process Timeline

Design Methods: Cost Model Data Collection Method Sources of Cost Data

Design Requirements Process Map Cost Model Process Map Cost Model Clear, neat, and within scope Able to be easily incorporated into a paper for publication Cost Model Accurate representation of true cost Process Map Cost Model Accurate representation of true cost Clear, neat, and within scope Able to be easily incorporated into a paper for publication

Design Constraints Data Collection Process Map Cost Model ED policy on who receives contrast Oral contrast administration is a long, rare process Process Map Project Scope Cost Model Only one year of retrospective data Nurse/patient interaction times are limited to observation data

Design Standards National Michigan Best Practices HIPAA ATSM E1699: Standard Practice for Performing VE/VA of Projects, Products, and Processes Institutional costing data cannot be published PEERRS Training Standard value stream mapping symbols TDABC

Recommendations 1 Validation of policy change 2 Method for evaluating future policy changes

Expected Impact Potential future policy changes Incentive for similar policies in other emergency departments across the country

Questions?