1. Cost-Containment Project: “Just a Liter of Normal Saline” Mohammad Usman Qazi, PGY2 Department of Internal Medicine

2. Goal Project goal: –To determine if prescription of intravenous fluid therapy in medicine admissions is appropriate –Calculate cost of IVF therapy to the hospital in cases where it is not indicated (both on admission and maintenance) –Identify areas for improvement

3. Intravenous Fluid Therapy Inclusion Criteria: –Admission to med/surg or telemetry floors from ED or transferred from ICU Exclusion Criteria: –Patients transferred from OSH –Patients admitted with septic shock

4. Indications for IVF: Indications for the prescription of intravenous fluids I. Highest priority a) Defend hemodynamics 1. Re-expand a severely contracted ECF volume 2. Prevent a fall in blood pressure when venous tone is low (e.g., anaesthesia) b) Return the ICF volume towards normal 1. Acute hyponatraemia that is symptomatic 2. Chronic hyponatraemia with a seizure 3. Chronic asymptomatic hyponatraemia II. Moderate priority 1. Re-expand a modestly contracted ECF volume Replace ongoing losses Avoid oliguria Match estimated electrolyte-free water loss in sweat and in the GI tract How to select optimal maintenance intravenous fluid therapy. Shafiee M, Bohn D, Hoorn E, et al. Q J Med; 2000. 96:601-610

5. Study Methods Admission IVF Indication: –Severe sepsis –Any hemodynamic instability (due to GI bleed etc) –Fluid resuscitation (diarrhea, vomiting, pancreatitis, acute kidney injury, DKA) –Burns Maintenance IVF indication: –Patient NPO –Patient with poor nutritional intake –Correction of electrolyte abnormalities –Oliguria and/or AKI

6. Methods Continued: Randomly selected 22 participants from patients (55 total) currently on the 6 medicine services at UCI Medical Center. –Exclusion and Inclusion criteria utilized IVF boluses given at admission recorded as well as any maintenance fluid started (with duration) Diet Recorded –Charts reviewed, and if no mention of poor nutrition assumed patient eating diet Recorded L of IVF given on admission where not indicated  cost per admission calculated L of maintenance IVF used per day recorded in patients where IVF not indicated  cost per day calculated for % of patients where IVF not indicated Please see supplementary information for table

7. Results: Number of Patients: 22 Patients given IVF on Admission: 16/22 Patients where IVF was indicated on Admission: 4/16 (25%) Total Liters of fluids given on admission to 12 patients where they were not indicated: 19.3L Avg L/admission: 1.6L Avg cost of 1L Bag of IVF: $10 Cost/admission to medicine: $16/admission Average # of admissions to medicine/day: 10 (75% with no indication for IVF) Cost/day of admissions when IVF not indicated: $120 Cost/year of admissions when IVF not indicated: $43,800

8. Results Continued Total Number of Patients: 22 Patients receiving maintenance IVF: 15/22 (68%) Patients where maintenance IVF was indicated: 2/15 (13%) Therefore, in approximately 87% maintenance IVF NOT indicated Total L/day used in 13/15 (87%) of patients where IVF not indicated: 28.3L  2.2L/day per patient Please see supplementary information for table

9. Results Continued One bag of IVF is ~$10 2.2L/day per patient  $22/day/patient Number of Medicine patients at time of study: 55 –0.87*55: 48 –Extra cost for unnecessary maintenance IVF tx: 48 x $22/day: $1056/day –Cost per year: $385,440

10. Costs Combined Adding the costs from admission and maintenance IVF that are not indicated: – $43800 + $385440 = $429,240/year

11. Study Limitations Limited sample size Patients limited to medicine service, therefore limiting generalization to other services The percentage of meal consumption not determined (If not recorded in H&P/progress note, assumed patient with adequate po intake) Differences in reimbursement methodology in various hospitals (?higher reimbursements with billing for IVF)

12. Learning Points Physicians in the Emergency Department as well as those in the Department of Internal Medicine should be educated about the indications for IVF Patient charts should be reviewed daily to see if IVF indicated Medical personnel should be made aware of the cumulative cost of IVF therapy