title: High-value care in the surgical intensive care unit: effect on ancillary resources.
abstract: Changes in health care policies have influenced transformations in hospital systems to be cost-efficient while maintaining robust outcomes. This is particularly important in intensive care units where significant resources are used to care for critically ill patients. We sought to determine whether high-value care processes (HVCp) implemented in a surgical intensive care unit (SICU) have an impact on commonly used ancillary tests.
  
  
  
  An implementation phase using a Lean Six Sigma approach was performed in October 2014 at a 24-bed large academic center SICU with aims to decrease orders of excessive daily laboratory tests and X-rays. The HVCp implemented included use of daily checklists, staff education, and visual reminders emphasizing the importance of appropriate laboratory tests and chest X-rays. Preintervention (July 2014-October 2014) and post-intervention (November 2014-June 2015) phases were compared.
  
  
  
  Average SICU census, case mix index (4.3 versus 4.4, P = 0.57), all patient refined severity of illness (3.2 versus 3.2, P = 0.91), and SICU mortality (7.1% versus 5.1%, P = 0.18) were similar in both phases. A significant reduction of excessive laboratory tests was evident after the implementation period. Eight hundred sixty-five arterial blood gases/mo were obtained in the preintervention phase compared with 420 arterial blood gases/mo after intervention (P = 0.004), representing a 51.4% reduction. Similar results were obtained with complete blood counts, basic metabolic profiles, coagulation profiles, and chest X-rays (12%, 17.8%, 30.2%, and 20.3% reductions, respectively), a total estimated cost savings of $59,137/mo and prevention of excess phlebotomy of approximately 4 L of blood/mo.
  
  
  
  By implementing an HVCp including a checklist, visual reminders, and provider education, we significantly reduced the use of commonly ordered ancillary tests in the SICU without affecting outcomes, resulting in an annual cost savings of $710,000.
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Ara
authors.initials: A
authors.lastname: Ko
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Jason S
authors.initials: JS
authors.lastname: Murry
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: David M
authors.initials: DM
authors.lastname: Hoang
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Megan Y
authors.initials: MY
authors.lastname: Harada
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Lia
authors.initials: L
authors.lastname: Aquino
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Charles
authors.initials: C
authors.lastname: Coffey
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Harry C
authors.initials: HC
authors.lastname: Sax
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California. Electronic address: rodrigo.alban@cshs.org.
authors.forename: Rodrigo F
authors.initials: RF
authors.lastname: Alban
mesh_terms: D002140:California; D057189:Checklist; D003363:Cost Control; D003422:Critical Care / Q000191:economics / Q000379:methods / Q000458:organization & administration*; D004502:Education, Medical, Continuing; D004509:Education, Nursing, Continuing; D017721:Hospital Costs / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000458:organization & administration*; D007396:Internship and Residency; D010043:Outcome and Process Assessment, Health Care; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration*; D012189:Retrospective Studies; D019564:Unnecessary Procedures / Q000191:economics / Q000706:statistics & numerical data*
keywords: Cost-containment; High-value care; Intensive care unit; Lean Six Sigma; Quality improvement