1. Samantha Ketchin, Clinical Analyst Auckland DHB
Investigating the Effect on Cost and Length of Stay (LOS) for Patients with Pressure Injuries (PI)
Samantha Ketchin, Clinical Analyst
Auckland DHB
Healthy Communities, Quality Healthcare

2. Pressure Injuries
Injury to skin/tissue caused by pressure and/or shear
Patients experience:
Pain
Increased susceptibility to infection
Delayed recovery
Psychological distress
Reduced quality of life

3. Organisational Priority
Target: Reduce number of PIs by 20%
Measure number of PI patients
Implement changes in practice
Measure again
Identify benefits:
Patient benefits
Calculate increased hospital cost for PI patients
Attribute cost saving to reduced prevalence
N.B. Only costs associated with the patient’s hospital stay are covered in this presentation

4. Some Studies - Costs Bennett G, Dealey C & Posnett J (2003)
£1000 (Grade 1) – £10,500 (Grade 4)
Extra costs to treat patients with PI
Calculated by:
Time taken to heal (from other studies)
Estimated costs for treatment
Costs not solely associated with hospital stay
Pappas S (2008)
US$25 (Surgical Patients) - US$2400 (Medical Patients)
Additional nursing costs for treating PI patients
Study highlights limitations in attributing causality
Padula W, Mishra M, Makic M, Sullivan P (2011)
US$500 - $70,000
Additional hospital costs for treating PI patients
Wide variation

5. Some Studies - LoS Cho, Ketefian, Barkauskas, Smith (2003)
1.84-fold increase in LoS
Other studies mention but do not quantify increased LoS

6. The key question…
Can we make reliable statements about hospital costs & LOS for PI patients using our own data?

7. ADHB Data Baseline audit (one day snapshot) of 1149 patients
75 patients with Pressure Injuries (PI)
55 patients acquired the PI during their hospital stay (HAPI)
3 patients excluded from analysis (unavailable diagnoses)

8. ADHB Study Identified control patients based on:
Age bracket
Specialty
Main diagnosis (of presenting event)
2734 control patients identified
Calculated LOS and costs for complete hospital stay
Compared average LOS and costs with PI patients

9. Results Costs: Extra $39,045 per patient LOS: 3.1 times longer
Published studies show:
Costs: Extra $39,045 per patient
LOS: 3.1 times longer
Estimated Yearly Savings:
Average cost per event calculated
No. of discharge events in 2011 = 38,800 (29,927 patients)
Approx. 6.7% with PI = 2600
20% of PIs = 520
20% reduction in PI:
Bed days saved = 7,115
Cost saved = $12.4M
Grade 4: £10,500 ($21,000)
1.9 times longer
Doubts about data

10. Reasons to Question Too good to be true?
Results do not align with those of published studies
A number of issues identified

11. Variability of data
Grade 1
Grade 2
Costs
LOS

12. Health Status
Assumption made about equal states of health in control and PI groups
50% of PI patients on cardiac ICU
Should we add the ward as a criteria to identify control patients – and which of their wards should we use?
Is primary diagnosis enough – should we use DRG and/or other measures?

13. Prevalence vs Incidence
Prevalence = no. of cases at a given time (snapshot) = 6.7%
Incidence = rate of new cases within a time period
Extrapolating results to estimate yearly savings
The European Pressure Ulcer Advisory Panel: pressure ulcer incidence is the most appropriate approach if the goal is to understand how the introduction of new protocols and interventions has affected the number of patients with pressure ulcers or to predict pressure ulcers or develop and evaluate risk assessment scales.

14. ADHB Yearly Calculations
Calculation of number of PI patients in one year likely to be much lower than the 6.7% prevalence figure used

15. Calculating Incidence
Time-consuming
Requires data to be gathered over a period of time
Potential to use coding to ascertain the number of PI patients in 1 year… but:
Coding does not always indicate PI (only 14 audit PI patients had a coding of PI)
Coding does not currently indicate whether hospital acquired
Should we attempt to calculate incidence to estimate cost and LOS savings?
Is prevalence a good means of demonstrating reduction?

16. Prevalence and Incidence
European Pressure Ulcer Advisory Panel:
Grade 1 pressure ulcers should be recorded as ‘warning signals’, but not included in the calculation of either prevalence or incidence rates.
75% of HAPIs are grade 1 (baseline audit)
Should we include grade 1 PIs in our prevalence and incidence calculations?

17. Cost of Prevention Assess requirements Potential need for:
Additional specialist equipment
Additional resource
Factor in these costs

18. Conclusion Current calculations are unreliable
It’s hard to calculate the effect of PI on LOS and Cost:
Many factors
Many questions
A lot of uncertainty
Opportunities for research to improve validity of results
Need clinical input into identification of control patients