The costs of fluid overload in the adult intensive care unit: is a small-volume infusion model a proactive solution?

ClinicoEconomics and Outcomes Research Dovepress open access to scientific and medical research O r i g i n a l R e s e a rc h ClinicoEconomics and Outcomes Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Open Access Full Text Article The costs of fluid overload in the adult intensive care unit: is a small-volume infusion model a proactive solution? This article was published in the following Dove Press journal: ClinicoEconomics and Outcomes Research 15 December 2014 Number of times this article has been viewed Debra L Child 1 Zhun Cao 2 Laura E Seiberlich 1 Harold Brown 2 Jordan Greenberg 1 Anne Swanson 1 Martha R Sewall 1 Scott B Robinson 2 Smiths Medical, ASD, Inc., St Paul, MN, USA; 2Premier Inc., Charlotte, NC, USA 1 Purpose: Fluid overload (FO) in critically ill patients remains a challenging clinical dilemma, and many continuous intravenous (IV) medications in the US are being delivered as a dilute solution, adding significantly to a patient’s daily intake. This study describes the costs and outcomes of FO in patients receiving multiple continuous infusions. Materials and methods: A retrospective study was conducted using a hospital administrative database covering .500 US hospitals. An FO cohort included adult intensive care unit (ICU) patients with a central line receiving IV loop diuretics and 2+ continuous IV infusions on 50%+ of their ICU days; a directly matched non-FO cohort included patients without IV diuretic use. The primary outcome of the study was total hospitalization costs per visit. Additional outcomes were ICU costs, mortality, total and ICU length of stay (LOS), 30-day readmission rates, and ventilator use. Unadjusted descriptive analysis was performed using chi-squared or paired t-tests to compare outcomes between the two cohorts. Results: A total of 63,974 patients were identified in each cohort. The total hospitalization cost per visit for the FO cohort was US$15,344 higher than the non-FO cohort (US$42,386 vs US$27,042), and the ICU cost for the FO cohort was US$5,243 higher than the non-FO cohort (US$10,902 vs US$5,659). FO patients had higher mortality (20% vs 16.8%), prolonged LOS (11.5 vs 8.0 days), longer ICU LOS (6.2 vs 3.6 days), higher risk of 30-day readmission (21.8% vs 21.3%), and ventilator usage (47.7% vs 28.3%) than the non-FO cohort (all P,0.05). Conclusion: In patients receiving multiple continuous infusions, FO is associated with increased health care resources and costs. Maximally concentrating medications and proactively providing continuous medications in small-volume infusions (SVI) could be a potential solution to prevent iatrogenic FO in critically ill patients. Further prospective research is warranted to assess the impact of the SVI dispensing model on patient outcomes and health care costs. Keywords: intensive care unit, conservative fluid management, hospital cost, length of stay Introduction Correspondence: Debra L Child Smiths Medical, ASD, Inc., 1265 Grey Fox Road, St Paul, MN, USA Tel +1 303 319 4976 Email 1 submit your manuscript | www.dovepress.com ClinicoEconomics and Outcomes Research 2015:7 1–8 Dovepress © 2015 Child et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php http://dx.doi.org/10.2147/CEOR.S72776 Powered by TCPDF (www.tcpdf.org) Limited information regarding the relationship between medication administration and fluid balance appears within clinical literature; however, the importance of fluid balance and the prevention of fluid overload (FO) in many disease states remains a prevalent discussion both clinically and economically.1–19 Fluid restriction via enhanced recovery after surgery (ERAS) or other similar initiatives is considered safe and effective and reported to decrease postoperative complications and hospital length of stay (LOS).1,2,5,8,15,20 In 2005, Brouse et al demonstrated an intensive care unit (ICU) LOS increase of 3.1 days in heart failure patients receiving .1.25 L of fluid per day compared to patients receiving ,1.25 L daily.7 Magee and Zbrozek reported similar clinical findings for transfusion-associated FO and demonstrated an adjusted incremental hospital Dovepress ClinicoEconomics and Outcomes Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Child et al cost of US$14,062 per visit compared to the non-FO patients, concluding that the incidence of FO is underreported, albeit substantial.21 Once diagnosed, FO is treated with diuretics or costly mechanical fluid removal methods such as dialysis or ultrafiltration.18,20,22 Intravenous (IV) loop diuretics are the mainstay of treatment, yet diuretics are associated with numerous complications, most notably renal failure and/or electrolyte disturbances that can lead to cardiac arrhythmias and sudden death.23–25 The replacement of essential electrolytes is also not without risk of serious side effects and further iatrogenic FO.26 To minimize the concern of FO and prevent this vicious treatment cycle, proactive conservative fluid management is recommended.1–5,8,18–20,27 Various techniques exist, but each involves restricting IV fluid volume administered to patients. However, particularly in the US, critical infusions are commonly delivered to adult patients using dilute solutions and a large volume pump. Large-volume drug infusions can significantly contribute to a patient’s daily fluid intake and impose a risk of FO.18 One therapeutic option to achieve conservative fluid management is predicated on the administration of maximally concentrated medications via syringe pump, also known as small-volume infusion (SVI). The SVI delivery method is widely used outside the US, in countries such as the UK, as the main method for adult IV medication administration for drugs with a short half-life or narrow therapeutic margin.28 However, in the US, delivering maximally concentrated continuous medications as standard of care in adult areas is generally limited or only implemented once patients have entered the cycle of FO and diuresis. While literature on the benefit of conservative fluid management is abundant, there has been little study examining the clinical or economic impacts of iatrogenic FO. Therefore, as an initial step, a retrospective descriptive study was conducted using a large hospital administrative database to describe an FO patient population in the adult ICU that wa (...truncated)