A Strategy for Inpatient Integration

Terry Horton, MD, FACPDelaware Valley NodeSeptember 21, 2010

Hospitals Inpatient Services Aggregate the Highly Disordered

Much higher rates of AUD and SA compared to general society, most are dependent*

Significant medical comorbidities Expensive revolving door

higher use of ER (2.3x), inpatient care (6.7x)** Increased AMA, readmissions

* Saitz, 2007; Bertholet, 2010** Stein, 1993

Hospitals have an Emerging Imperative

Need to Improve: Safety Health care costs Joint Commission

compliance

Hospitals Need Best Methods/tools to:

Screen and diagnose – must be pragmatic Effectively treat withdrawal Engage and transition into ongoing drug tx

SBIRT not effective for inpatients but Linkage to tx improves outcome*

* Bertholet, 2010

Delaware’s Epidemiology

Estimated 2009 population of 885,000 9% of adults alcohol/drug abusing or

dependent* 65,000 in need of alcohol/drug treatment** 8,216 admissions to publicly-funded SA

treatment services statewide 2006***

* 2004-2005 NSDUH data** Wright et al. 2007*** Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health, 2007

Tx gap

Delaware’s Primary Hospital System

• Wilmington/Christiana Hospitals

• 1100 beds

• 160,491 ER visits

• 54,597 admissions*

• No in-house substance abuse/etoh service

*2009 data

CCHS prior to 2009

No standardized ETOH/Substance abuse screening SBIRT for trauma service only

No standardized withdrawal treatment protocols or monitoring

Social Work consult for referral 3 root cause analyses in 2007-8 directly

related to delirium and tremens

2008-9 CCHS Epidemiology

Less than expected rates of ETOH withdrawal

( 0.75% actual vs. 0.9-1.25% calc) 2x more DTs than expected

(0.2% vs. 0.05-.125%) Majority of DTs are secondary dx’s

115/179 (64%) 1/1/08-7/31/09 23% >= 65 years old

Deaths more common in secondary dx: 19/20

The Intervention

ETOH Withdrawal Symptom Order Set launched on October 6, 2009 for med/surg inpatients includes screening tool for risk of AW CIWA clinical assessment/scoring Score triggered treatment and monitoring

protocol

Outcomes: Improved Safety

No Sentinel Events since launch Significant reduction of submitted

cases to DOM No cases to date associated with over-

treatment

Quarterly Outcomes Data

Secondary Diagnoses Summary

28 22 27 29

12 16

0

20

40

60

80

100

1Q09 2Q09 3Q09 4Q09 1Q10 2Q10

Quarters

Num

ber o

f Pat

ient

s

Sec DX of AW

Sec DX of DT

Protocol launch

Restraints Use

Percentage of AW and DT Patients with Restraint

0

20

40

60

80

AW DT

Diagnosis

Perc

en

tag

e

Pre

Post

ICU Transfers

Percentage of AW and DT patients Transferred from Floor to ICU

0

5

10

15

20

25

AW DT

Diagnosis

Per

cent

age

Pre

Post

Length of Stay

Delirium Tremens DiagnosisALOS

8.93 9.89

15.4313.48

7.5010.34

0

5

10

15

20

Q1'09 Q2'09 Q3'09 Q4'09 Q1'10 Q2'10

Day

s

Protocol launch

Project Engagement

Community partner imbedded at WH Peer-to-peer inpt/outpt intervention Data Review

N = 313 (9/1/08- 6/10/10) 35% successfully admitted into 33 inpt/out

drug/alcohol treatment programs

Project Engagement: Partnering with DPCI/Aetna

Claims from June 1, 2009 - November 30, 2009 3 months before and after claims review, n = 18

Metric Pre Post Finding

Medical inpatient admits 12 8 33% decrease

ER visits 54 33 38% decrease

BH/SA inpatient admits 7 10 43% increase

BH/SA outpatient visits 12 16 33% increase

PCP office visits 27 51 88% increase

Delaware Physicians Care Inc, May, 2010

CTN Opportunities for Inpatient-based Research

Define/develop pragmatic tools and protocols to screen and improve safety

Develop and test methods to engagement and link into ongoing drug/etoh treatment

Study clinical and fiscal outcomes