CLINICAL OBSERVATION Nutrition Support Team Recommendations Can Reduce Hospital Costs MARGOT F. ROBERTS, MSN, RN, CNSN, AND GARY M. LEVINE, MD Division of Gastroenterology and Nutrition, Department of Medicine, Albert Einstein Medical University School of Medicine, Philadelphia
ABSTRACT: Providing nutrition support may be costly to hospitals under the prospective payment system. A nutrition support team, however, can be effective in controlling costs. To demonstrate the importance of the nutrition support team and to quantify the potential cost savings that can be achieved, a retrospective review of the effect of our team on hospital costs was conducted for the 12-month period of October 1989 to September 1990. The team supervises but does not regulate the use of total parenteral nutrition (TPN). During this time period, 176 patients received TPN. In 14 patients, the use of TPN was inappropriate, representing $65,349 in excess costs. After the cost of providing enteral nutrition to these patients (estimated at $2,430) was deducted, a net loss of $62,919 occurred. Nutrition support team action saved an additional $45,186 in hospital charges when recommendations to discontinue TPN were eventually heeded. Nutrition support team approval before TPN is initiated would achieve cost savings.
TPN were more resource intensive than average for each DRG. ProPac calculated that hospitals were being reimbursed an average of only 62 cents for every dollar spent on TPN patient, and 15% of TPN patients were
outliers.2 Outliers
are patients who either have an extremely long length of stay or extremely high costs compared with most discharged patients classified in the same DRG.3 Consequently, the inappropriate use of
further increase the difference between hosrevenue. In 1986, O’Brien et al found that during a 16-month period at the California Irvine Medical Center, 14 patients received TPN against nutrition support team (NST) recommendations.4 This represented 280 days of TPN, with total charges equaling $70,200 (more than $5,000 per patient). The prospective payment system has forced hospitals to examine the costs of providing care. To reduce costs, hospital administrators may review the cost of maintaining an NST and find it is one possible area for budget cuts. To demonstrate the importance of an NST and to quantify the potential cost savings that an NST can achieve if recommendations are followed, a retrospective review of the effect of our team on hospital costs was conducted for the 12-month period from October 1989 to September 1990. At our 500-bed institution, Medicare/Medicaid patients represent 62 to 65% of our population, thereby increasing the potential for excessive costs associated with TPN relative to hospital revenue. Another factor that may result in the inappropriate use of TPN is that physicians are not required to receive approval by the NST to initiate TPN.
on the discharge of the of diagnosis patient irrespective the actual costs borne by the hospital for Medicare patients. Since that time, other insurers have also used this type of reimbursement. Some economists predict that by 1995 all medical insurers will use a prospective payment system.’ Providing nutrition support may be costly to hospitals in a prospective payment system. If a Medicare
preset
Temple
patient requires total parenteral nutrition (TPN) or enteral nutrition, the cost of this therapy is not directly reimbursable but is included within the DRG payment rate for each diagnosis. Hospitals do not receive higher reimbursement on the basis of the need for parenteral or enteral nutrition other than the supplemental payment for malnutrition as a comorbidity. In 1988, the Prospective PaymentAssessment Commission (ProPac), formed by Congress, found that patients requiring
Substantial changes are occurring in the delivery of medical care in the United States. These changes began in 1983 when Medicare instituted a prospective payment system using diagnosis related groups (DRGs) to pay for health care. Since 1983, hospitals have received a
Center and
amount of money based
Address for reprints: Margot F. Roberts, MSN, RN, Nutrition Support Service, Department of Surgery, Suite 1100, Pepper Pavilion, Graduate Hospital, 1800 Lombard Street, Philadelphia, PA 19146.
TPN
can
pital
expenses and
227
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
228
QUALITY ASSURANCE REVIEW Our NST is composed of a gastroenterologist who is the head of medical nutrition and who reviews all nutrition support patients biweekly, a general surgeon who reviews all surgical nutrition support patients weekly, a registered dietitian who monitors and performs quarterly quality assurance audits for enterally fed patients, and a registered nurse who does the same for parenterally fed patients. The quality assurance audits performed during the period of study were reviewed to find cases where TPN was used inappropriately, to calculate the charges for inappropriate TPN, and to quantify savings when recommendations from the NST to discontinue inappropriate TPN were heeded. For the purpose of this report, only those quality assurance items pertinent to costs were considered
(Table 1). Reviews of indicators of nutrition care are routinely carried out and reviewed quarterly by the head of medical nutrition. The results are disseminated to the hospital’s quality assurance department. Individual physicians (staff and residents) are notified of each instance in which their nutrition care was questioned. The records of all patients receiving TPN are reviewed for adequacy of delivery. Cases are reviewed for both overfeeding or insufficiency of calories (±2100 kJ from NST recommendations) on the basis of the Harris Benedict equation, stress factors, and indirect calorimetry. The appropriateness of TPN and the presence of complications such as pneumothorax after central venous catheter insertion and catheter-related sepsis are monitored. TPN is considered inappropriate in patients having a functional gastrointestinal tract or severe irreversible disease (eg, terminal cancer, brain death). In patients with a functional gastrointestinal tract, the NST advocates the use of duodenal infusion via small bore feeding tubes. Cases in which the patient had a functioning gastrointestinal tract but access could not be obtained because of facial or basilar skull fractures are considered appropriate for TPN. On the basis of risk-benefit analysis of TPN complications, TPN for fewer than 5 days is considered inappropriate.55
If a patient is started on TPN but the assessment of the NST considers TPN inappropriate or if a patient progresses to the point that enteral feeding can begin, the dietitian or nurse discusses the case with either the housestaff or attending physician who is encouraged to attempt enteral feeding. If this approach is unsuccessful, the NST reviews the patient case with the head of either medical or surgical nutrition. Their interventions are usually successful in switching the patient from TPN to enteral nutrition. CLINICAL OBSERVATIONS
From October 1989 to September 1990,176 patients received TPN. In 14 patients, the use of TPN was judged to be inappropriate. These patients received a total of 87 days of TPN. If NST recommendations were followed, this would have translated into 78 patient days of enteral feedings. (In four cases, the patient was tolerating a regular diet less than 5 days after TPN was started). On the basis of institutional charges listed in Table 2, the inappropriate use of TPN represents $65,349 in excess charges. This analysis includes the changes associated with one episode of catheter sepsis. Because most of these patients were Medicare outliers, most of the $65,349 was not recovered by the hospital. Had these patients received enteral nutrition, these charges would have been $2,430, for a net saving of $62,919. Table 3 illustrates the combined charges of TPN versus enteral feedings. Fluoroscopically placed feeding tubes were not used in this population; therefore, this charge is not included in the comparison of
charges. Table 2.
Component charges related to
nutrition support
Table 1. Selected quality assurance indicators for parenteral nutrition support
*
*
Point at which quality
begun.
assurance
review of individual
cases
is
Except as referenced, actual hospital charges. t Until blood sugars are stable. $ Daily electrolytes, blood urea nitrogen, glucose x 7. Thereafter, electrolytes, blood urea nitrogen, glucose on Monday, Wednesday, and Friday. Serum calcium, phosphate, magnesium every other day x 3, then every Monday. Complete blood count, albumin, bilirubin, serum glutamic-oxaloacetic transaminases, alkaline phosphates, creatinine, cholesterol, triglycerides every Monday.
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
229 Table 3.
Comparison of charges
in
cases
of
inappropriate TPN
*
Differences in TPN charges are based on whether patient received daily lipids or multivitamins, whether he or she was on a medical service, whether he or she needed a surgical consult for line insertion; and the number of times his or her vascular access was changed. In two cases, the vascular access was changed twice, and in one case, the vascular access was changed five times. Line insertion costs were charged twice in one case where a new vascular access was obtained in a different site. or
Table 4 illustrates the savings in TPN charges for the same group of patients beginning at the time the recommendation of the NST was heeded to discontinue TPN and use enteral feeding. The number of days represents the length of time TPN was stopped until the day the patient was either tolerating a regular diet or transferred to another facility. One of the 14 patients died. Table 4 demonstrates that the NST action prevented 82 patient days of TPN, which would have resulted in an additional $45,186 in hospital charges. Table 4. Savings based on the recommendations of the NST to discontinue TPN and use enteral feeding
Because 10 (71%) of these 14 patients were Medicare outliers, the majority of charges would not have been reimbursed. No complications of enteral therapy such as aspiration or bronchial cannulation were found in these patients. DISCUSSION
Determining actual costs and time required to provide nutrition support is extremely difficult. Actual costs and charges (what is asked for payment) are two different entities. Actual costs do not include overhead such as building, maintenance, labor costs, utilities and equipment costs associated with TPN delivery. These overhead costs extend to the clinical laboratory and radiology and nursing departments that provide services to the TPN patients.5 It was for these reasons that only charges were compared. The major finding of this review is that closer super-
*
Days represent time from the day TPN was stopped until the day the patient either tolerated a regular diet, died, or was transferred to another facility.
vision of the use of TPN would achieve substantial cost savings. If our institution required NST approval before TPN was initiated, the hospital could minimize the needless use of resources. In the 12-month period observed, NST action saved $45,186 and could have achieved additional savings of $62,919. These data were presented to the medical quality assurance committee as a first step toward establishing a policy requiring NST approval before initiating TPN. The NST also carries out other cost-saving activities that were not quantified in this observation. These include promoting timely TPN formula changes, which
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
230
prevents the unnecessary discarding of solutions well
as
metabolic complications; requesting catheter changes (which, when not performed, often lead to sepsis and increased length of stay); reducing the number of laboratory tests when TPN is discontinued; and preventing overfeeding and thus avoid impeding successful ventilator weaning, which could lead to increased length of stay.s>8 NSTs may justify their existence by specifying the most beneficial therapy at the most cost-effective method for the hospital. as
REFERENCES 1.
2.
Torosian LC, CunliffM. Nutritional support nursing in a changing health care environment: administrative issues. In: Grant JA, Kennedy-Caldwell C, eds. Nutrition support in nursing. Philadelphia: Grune & Stratton, 1988:355-8. Regenstein M. Reimbursement for nutrition support. NCP
1989;4:194-201. 3.
4.
Parver A. Reimbursement for parenteral and enteral nutrition. [A.S.P.E.N. monograph], Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 1985:8-9. O’Brien DD, Hodges RE, Day AT, et al. Recommendations of nutrition support team promote cost containment. JPEN
1986;10:300-2. 5.
Twomey PL, Patching SC. Cost-effectiveness of nutritional
ACKNOWLEDGMENTS
6.
The authors thank Cathy McKinney, MSN, RN, for her assistance in data collection, Mrs. Jackie Mimless
7.
Mirtallo JM, Powell CR, Campbell SM, et al. Cost-effective nutrition support. Nutr Clin Pract 1987;2:142-51. Anderson GF, Steinberg EP. DRG’s and specialized nutrition support. Prospective payment and nutritional support: the need for reform. JPEN 1986;10:3-8. Kovacevich DS. Nutritional alterations in illness: Pulmonary. In: Kennedy-Caldwell C, Guenter PA, eds. Nutrition support nursing core curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 1988:309-26.
support. JPEN 1985;9:3-10.
for
preparation of the manuscript, and Karen Gilbert, MSN, RN, CNSN, and Marjorie Goldstein, MBA, RD,
for much
thoughtful discussion.
8.
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
ABSTRACT: Providing nutrition support may be costly to hospitals under the prospective payment system. A nutrition support team, however, can be effective in controlling costs. To demonstrate the importance of the nutrition support team and to quantify the potential cost savings that can be achieved, a retrospective review of the effect of our team on hospital costs was conducted for the 12-month period of October 1989 to September 1990. The team supervises but does not regulate the use of total parenteral nutrition (TPN). During this time period, 176 patients received TPN. In 14 patients, the use of TPN was inappropriate, representing $65,349 in excess costs. After the cost of providing enteral nutrition to these patients (estimated at $2,430) was deducted, a net loss of $62,919 occurred. Nutrition support team action saved an additional $45,186 in hospital charges when recommendations to discontinue TPN were eventually heeded. Nutrition support team approval before TPN is initiated would achieve cost savings.
TPN were more resource intensive than average for each DRG. ProPac calculated that hospitals were being reimbursed an average of only 62 cents for every dollar spent on TPN patient, and 15% of TPN patients were
outliers.2 Outliers
are patients who either have an extremely long length of stay or extremely high costs compared with most discharged patients classified in the same DRG.3 Consequently, the inappropriate use of
further increase the difference between hosrevenue. In 1986, O’Brien et al found that during a 16-month period at the California Irvine Medical Center, 14 patients received TPN against nutrition support team (NST) recommendations.4 This represented 280 days of TPN, with total charges equaling $70,200 (more than $5,000 per patient). The prospective payment system has forced hospitals to examine the costs of providing care. To reduce costs, hospital administrators may review the cost of maintaining an NST and find it is one possible area for budget cuts. To demonstrate the importance of an NST and to quantify the potential cost savings that an NST can achieve if recommendations are followed, a retrospective review of the effect of our team on hospital costs was conducted for the 12-month period from October 1989 to September 1990. At our 500-bed institution, Medicare/Medicaid patients represent 62 to 65% of our population, thereby increasing the potential for excessive costs associated with TPN relative to hospital revenue. Another factor that may result in the inappropriate use of TPN is that physicians are not required to receive approval by the NST to initiate TPN.
on the discharge of the of diagnosis patient irrespective the actual costs borne by the hospital for Medicare patients. Since that time, other insurers have also used this type of reimbursement. Some economists predict that by 1995 all medical insurers will use a prospective payment system.’ Providing nutrition support may be costly to hospitals in a prospective payment system. If a Medicare
preset
Temple
patient requires total parenteral nutrition (TPN) or enteral nutrition, the cost of this therapy is not directly reimbursable but is included within the DRG payment rate for each diagnosis. Hospitals do not receive higher reimbursement on the basis of the need for parenteral or enteral nutrition other than the supplemental payment for malnutrition as a comorbidity. In 1988, the Prospective PaymentAssessment Commission (ProPac), formed by Congress, found that patients requiring
Substantial changes are occurring in the delivery of medical care in the United States. These changes began in 1983 when Medicare instituted a prospective payment system using diagnosis related groups (DRGs) to pay for health care. Since 1983, hospitals have received a
Center and
amount of money based
Address for reprints: Margot F. Roberts, MSN, RN, Nutrition Support Service, Department of Surgery, Suite 1100, Pepper Pavilion, Graduate Hospital, 1800 Lombard Street, Philadelphia, PA 19146.
TPN
can
pital
expenses and
227
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
228
QUALITY ASSURANCE REVIEW Our NST is composed of a gastroenterologist who is the head of medical nutrition and who reviews all nutrition support patients biweekly, a general surgeon who reviews all surgical nutrition support patients weekly, a registered dietitian who monitors and performs quarterly quality assurance audits for enterally fed patients, and a registered nurse who does the same for parenterally fed patients. The quality assurance audits performed during the period of study were reviewed to find cases where TPN was used inappropriately, to calculate the charges for inappropriate TPN, and to quantify savings when recommendations from the NST to discontinue inappropriate TPN were heeded. For the purpose of this report, only those quality assurance items pertinent to costs were considered
(Table 1). Reviews of indicators of nutrition care are routinely carried out and reviewed quarterly by the head of medical nutrition. The results are disseminated to the hospital’s quality assurance department. Individual physicians (staff and residents) are notified of each instance in which their nutrition care was questioned. The records of all patients receiving TPN are reviewed for adequacy of delivery. Cases are reviewed for both overfeeding or insufficiency of calories (±2100 kJ from NST recommendations) on the basis of the Harris Benedict equation, stress factors, and indirect calorimetry. The appropriateness of TPN and the presence of complications such as pneumothorax after central venous catheter insertion and catheter-related sepsis are monitored. TPN is considered inappropriate in patients having a functional gastrointestinal tract or severe irreversible disease (eg, terminal cancer, brain death). In patients with a functional gastrointestinal tract, the NST advocates the use of duodenal infusion via small bore feeding tubes. Cases in which the patient had a functioning gastrointestinal tract but access could not be obtained because of facial or basilar skull fractures are considered appropriate for TPN. On the basis of risk-benefit analysis of TPN complications, TPN for fewer than 5 days is considered inappropriate.55
If a patient is started on TPN but the assessment of the NST considers TPN inappropriate or if a patient progresses to the point that enteral feeding can begin, the dietitian or nurse discusses the case with either the housestaff or attending physician who is encouraged to attempt enteral feeding. If this approach is unsuccessful, the NST reviews the patient case with the head of either medical or surgical nutrition. Their interventions are usually successful in switching the patient from TPN to enteral nutrition. CLINICAL OBSERVATIONS
From October 1989 to September 1990,176 patients received TPN. In 14 patients, the use of TPN was judged to be inappropriate. These patients received a total of 87 days of TPN. If NST recommendations were followed, this would have translated into 78 patient days of enteral feedings. (In four cases, the patient was tolerating a regular diet less than 5 days after TPN was started). On the basis of institutional charges listed in Table 2, the inappropriate use of TPN represents $65,349 in excess charges. This analysis includes the changes associated with one episode of catheter sepsis. Because most of these patients were Medicare outliers, most of the $65,349 was not recovered by the hospital. Had these patients received enteral nutrition, these charges would have been $2,430, for a net saving of $62,919. Table 3 illustrates the combined charges of TPN versus enteral feedings. Fluoroscopically placed feeding tubes were not used in this population; therefore, this charge is not included in the comparison of
charges. Table 2.
Component charges related to
nutrition support
Table 1. Selected quality assurance indicators for parenteral nutrition support
*
*
Point at which quality
begun.
assurance
review of individual
cases
is
Except as referenced, actual hospital charges. t Until blood sugars are stable. $ Daily electrolytes, blood urea nitrogen, glucose x 7. Thereafter, electrolytes, blood urea nitrogen, glucose on Monday, Wednesday, and Friday. Serum calcium, phosphate, magnesium every other day x 3, then every Monday. Complete blood count, albumin, bilirubin, serum glutamic-oxaloacetic transaminases, alkaline phosphates, creatinine, cholesterol, triglycerides every Monday.
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
229 Table 3.
Comparison of charges
in
cases
of
inappropriate TPN
*
Differences in TPN charges are based on whether patient received daily lipids or multivitamins, whether he or she was on a medical service, whether he or she needed a surgical consult for line insertion; and the number of times his or her vascular access was changed. In two cases, the vascular access was changed twice, and in one case, the vascular access was changed five times. Line insertion costs were charged twice in one case where a new vascular access was obtained in a different site. or
Table 4 illustrates the savings in TPN charges for the same group of patients beginning at the time the recommendation of the NST was heeded to discontinue TPN and use enteral feeding. The number of days represents the length of time TPN was stopped until the day the patient was either tolerating a regular diet or transferred to another facility. One of the 14 patients died. Table 4 demonstrates that the NST action prevented 82 patient days of TPN, which would have resulted in an additional $45,186 in hospital charges. Table 4. Savings based on the recommendations of the NST to discontinue TPN and use enteral feeding
Because 10 (71%) of these 14 patients were Medicare outliers, the majority of charges would not have been reimbursed. No complications of enteral therapy such as aspiration or bronchial cannulation were found in these patients. DISCUSSION
Determining actual costs and time required to provide nutrition support is extremely difficult. Actual costs and charges (what is asked for payment) are two different entities. Actual costs do not include overhead such as building, maintenance, labor costs, utilities and equipment costs associated with TPN delivery. These overhead costs extend to the clinical laboratory and radiology and nursing departments that provide services to the TPN patients.5 It was for these reasons that only charges were compared. The major finding of this review is that closer super-
*
Days represent time from the day TPN was stopped until the day the patient either tolerated a regular diet, died, or was transferred to another facility.
vision of the use of TPN would achieve substantial cost savings. If our institution required NST approval before TPN was initiated, the hospital could minimize the needless use of resources. In the 12-month period observed, NST action saved $45,186 and could have achieved additional savings of $62,919. These data were presented to the medical quality assurance committee as a first step toward establishing a policy requiring NST approval before initiating TPN. The NST also carries out other cost-saving activities that were not quantified in this observation. These include promoting timely TPN formula changes, which
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
230
prevents the unnecessary discarding of solutions well
as
metabolic complications; requesting catheter changes (which, when not performed, often lead to sepsis and increased length of stay); reducing the number of laboratory tests when TPN is discontinued; and preventing overfeeding and thus avoid impeding successful ventilator weaning, which could lead to increased length of stay.s>8 NSTs may justify their existence by specifying the most beneficial therapy at the most cost-effective method for the hospital. as
REFERENCES 1.
2.
Torosian LC, CunliffM. Nutritional support nursing in a changing health care environment: administrative issues. In: Grant JA, Kennedy-Caldwell C, eds. Nutrition support in nursing. Philadelphia: Grune & Stratton, 1988:355-8. Regenstein M. Reimbursement for nutrition support. NCP
1989;4:194-201. 3.
4.
Parver A. Reimbursement for parenteral and enteral nutrition. [A.S.P.E.N. monograph], Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 1985:8-9. O’Brien DD, Hodges RE, Day AT, et al. Recommendations of nutrition support team promote cost containment. JPEN
1986;10:300-2. 5.
Twomey PL, Patching SC. Cost-effectiveness of nutritional
ACKNOWLEDGMENTS
6.
The authors thank Cathy McKinney, MSN, RN, for her assistance in data collection, Mrs. Jackie Mimless
7.
Mirtallo JM, Powell CR, Campbell SM, et al. Cost-effective nutrition support. Nutr Clin Pract 1987;2:142-51. Anderson GF, Steinberg EP. DRG’s and specialized nutrition support. Prospective payment and nutritional support: the need for reform. JPEN 1986;10:3-8. Kovacevich DS. Nutritional alterations in illness: Pulmonary. In: Kennedy-Caldwell C, Guenter PA, eds. Nutrition support nursing core curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 1988:309-26.
support. JPEN 1985;9:3-10.
for
preparation of the manuscript, and Karen Gilbert, MSN, RN, CNSN, and Marjorie Goldstein, MBA, RD,
for much
thoughtful discussion.
8.
Downloaded from ncp.sagepub.com at LAKEHEAD UNIV on March 17, 2015
