How to Know Which Patients to 'Watch Like a Hawk'

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.