Return on Investment: Just Knowing the Price Is Not Enough!* Neil A. Halpern, MD, MCCM Department of Anesthesiology and Critical Care Memorial Sloan Kettering Cancer Center New York, NY
David Shaz, MD Department of Medicine James J. Peters VA Medical Center Bronx, NY; and Department of Anesthesiology and Critical Care Memorial Sloan Kettering Cancer Center New York, NY
eturn on investment (ROI) is an integral component of the complicated process of introducing new tech nologies in critical care. Determining ROI is especially im portant for technologies that are costly, purport to have added values, but may also have negative values, and rely upon a num ber of business-related assumptions (1). Thus, build ing the ROI justification may be quite challenging because the variables involved may not be easily articulated, measured, or monetized (2-6). Costs are identified within confusing catego ries (i.e., direct, indirect, variable, and missed opportunity) and the num ber of added values is potentially endless. These may include advancing quality of care, standardizing tech nologies, improving workflow, throughput, efficiencies, staff teaching and patient safety, avoiding errors, enhancing record keeping, improving job satisfaction, meeting national m an dates, and opening up novel pathways to attract new patients or research projects. Potentially "negative" values (i.e. adjust ment to new care models and resistance to change) should also be monetized and factored into the ROI. Finally, assumptions built into the ROI may also be subject to unpredictable per turbations. For example, projected reimbursements may be decreased because of changes in billing rules (7). So the dilemma on the part of the champion of the new technology, in this case, the intensivist, is determining which components of the ROI need to be stressed. O f great import, the intensivist must figure out how the ROI variables will be measured
R
*See also p. 1862. Key Words: critical care; healthcare informatics; return on investment Supported, in part, by the Department of Anesthesiology and Critical Care at Memorial Sloan Kettering Cancer Center, NY. Dr. Halpern served as a board member for Pronia Medical, Instrumentation Lab, and Cardiopulmonary. Dr. Shaz has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0000000000000422 1952
w w w .c c m jo u r n a l.o r g
and ultimately quantified and reported. ROI calculations are rela tively straightforward when there is clear cause and effect (2, 8), but in our elaborate ICU world, the ROI arithmetic is much more complex (1). Even the learning curve and resources necessary to introduce new technologies must be factored into the cost (9). And how much improvement over current practice (i.e. 5%, 25%, or 50%) represents "success" within the ROI (10,11)? Hospitals commonly control the introduction of new technologies, particularly expensive and widely used devices, through a product evaluation and/or clinical device committee. Thus, the project champion needs to get involved in commit tee-based presentations, politicking, campaigning to get buyin from prospective users, and obtaining fiscal support. Since many new devices are actually healthcare informatics plat forms, the hospital’s informatics and biomedical engineering teams must be intimately involved to ensure that the project can be supported (12). This commonly involves an analysis of exist ing networks, interfaces, and middleware. Furthermore, new technologies should be assessed in the hospital’s simulation laboratory and then trialed in a controlled clinical pilot, hope fully vendor sponsored, with well-defined and measurable goals (13). The ROI cost projections should also factor in both the current and future costs of the informatics components (net work, software upgrades, yearly licenses, and vendor support). ROI projections in critical care may target cost savings through hoped for decreases in the ICU length of stay (LOS). Importantly, the ICU LOS data must differentiate between high acuity ICU days and extended stay lower acuity ICU days due to the inability to transfer clinically improved ICU patients to the wards. The ROI m ust also select from one of two m eth ods of calculating ICU and ward costs per day. The first uses previously published national average ICU and ward costs per day (14) as proxies representing the study hospital costs. In the second, the ROI process establishes the actual costs for each ICU and ward day using the hospital’s cost/charge database. The former uses macroeconomic data that may not be appli cable to the study hospital and assigns identical average costs per day for each day; whereas the latter is more preferable as the daily costs are directly calculated and relevant. When the intensivist is presenting the ROI proposal, it is very important to think about the “next day,” whenever that next day is. For example, if the new technology performs as predicted, and the assumptions inherent in the project are realized and the ROI works out, everything is great! On the other hand, what if the ROI does not come to pass as promised because “stuff” happens? Who suffers the consequences especially in a costly project with an overly exaggerated ROI? Therefore, the ROI calculus must be grounded in reality. It is important not to oversell the ROI, no matter how excited the intensivist feels about the project. Impor tantly, do not rely upon the vendor to provide all the background August 2 0 1 4 - Volume 42 • Number 8
Editorials
cost data and the many savings that will undoubtedly accrue. Remember, as cynical as this sounds, the main imperative for the vendor is to sell their merchandise. In this issue of Critical Care Medicine, Slight et al (15) pres ent a technology-based ROI study. Their ROI analysis is predi cated upon a previously published pre- and postinterventional trial of a continuous noninvasive m onitoring and alert system for heart and respiration rates and patient movement (16). This study was conducted on ward-based medical-surgical patients in a single com m unity hospital. Patients with alerts were either transferred to the ICU or remained on the ward. The intervention group (noninvasive m onitor) had shorter ICU and/or hospital lengths of stay than the control group (no intervention) and a significant decrease in code blue events (16). The largest ROI was observed in reduced LOS primarily for ward patients and at a lower level for ICU transfers. This study has great value in that it presents an in-depth look at ROI methodology using a healthcare informatics platform. Impor tantly, the investigators approach inpatient and ICU care and costs as one continuum. The authors delve into the challenging arena of obtaining start-up and ongoing informatics type costs includ ing hardware, software licenses, infrastructure, staff training, and ongoing operations and warranties. Benefits within the ROI calcu lations were tracked using hospital LOS for patients who remained on the ward, and hospital and ICU LOS for patients transferred from the ward to the ICU. The authors did not calculate their own ward and ICU daily costs; they proxied these costs using data from a prior study of Medicare beneficiaries (17). Potential for decreased pressure ulcers was also monetized. The authors incorporated both optimistic and pessimistic assumptions within a sensitivity analysis and present both liberal (total hospital LOS) and conservative (last day in ICU and hospital) models of cost savings so as not to over sell the ROI. Additionally, they factored cost indexing, inflationary rates, and break-even points into this 5-year study. There are some challenges associated with this study. First, the reader must rely upon the findings of a previously pub lished study in another journal (16) and data presented at an international meeting (18) to buy into the efficacy of the non invasive m onitoring device. Furthermore, the implication that a technology applied to non-ICU patients can be used in ROI calculations involving the ICU may represent a leap of faith that the ICU stay was actually impacted by the device. Addi tionally, as the authors note, many of the intangible elements of cost were not included, that is, workflow changes, decreases in nurses' exposure to alarm fatigue, benefits of early alerts for rapid response team activations, and less hands-on monitoring of the inpatient. Furthermore in this study, the most striking finding of a dramatic reduction in code blue events is not even addressed in the ROI. It is also quite difficult to make inter-institutional general izations regarding the ROI associated with healthcare infor matics platforms. This is due to the lack of comparability between informatics infrastructures, technologic capabilities,
Critical Care Medicine
and support among facilities. In addition, the level of interac tions between computerized alerts, rapid response teams, and front-line nursing differ significantly among hospitals. In conclusion, the authors lay out a very comprehensive ROI roadmap for new technology. But at the same time, this study demonstrates that even with a well-defined and sophisti cated understanding of the ROI process, in the end, the authors still “bet the house” on that well-trodden and easily measurable variable, LOS.
REFERENCES 1. P a s to re s S M , H a lp e rn N A : A c q u is itio n s tra te g ie s fo r c r itic a l c a re te c h n o lo g y . C rit C are C lin 2 0 0 0 ; 1 6 : 5 4 5 - 5 5 6 2. S a c h d e v a R C : M e a s u rin g th e im p a c t o f n e w te c h n o lo g y : A n o u tc o m e s -b a s e d a p p ro a c h . C rit C are M ed 2 0 0 1 ; 2 9 : N 1 9 0 - N 1 9 5 3 . W a n g SJ, M id d le to n B, P ro s s e r LA, e t al: A c o s t-b e n e fit a n a ly s is o f e le c tro n ic m e d ic a l re c o r d s in p rim a ry ca re . A m J M e d 2 0 0 3 ; 1 1 4 :3 9 7 - 4 0 3 4. H a rd y PA: G e ttin g a re tu rn o n in v e s tm e n t fro m s p e n d in g c a p ita l d o l la rs o n n e w b e d s . J H e a lth c M anag 2 0 0 4 ; 4 9 : 1 9 9 - 2 0 5 5. O rio l N E , C o te PJ, V ava sis AP, e t a l: C a lc u la tin g th e re tu rn o n in v e s t m e n t o f m o b ile h e a lth c a re . B M C M e d 2 0 0 9 ; 7 :2 7 6. M a n s fie ld J, J a rre tt S : U s in g s m a rt p u m p s to u n d e rs ta n d a n d e v a lu a te c lin ic ia n p ra c tic e p a tte rn s to e n s u re p a tie n t sa fe ty . H o sp Pharm 2 0 1 3 ; 4 8 :9 4 2 -9 5 0 7. C a s te lla n o s I, S c h u ttle r J, P ro k o s c h H U , e t al: D o e s in tro d u c tio n o f a P a tie n t D a ta M a n a g e m e n t S y s te m (P D M S ) im p ro v e th e fin a n c ia l s itu a tio n o f an in te n s iv e c a re u n it? B M C M e d Inform D e cis M ak 2 0 1 3 ; 1 3 :1 0 7 8. A le m i F, Z a rg o u s h M , O a k e s JL Jr, e t al: A s im p le m e th o d fo r c a u s a l a n a ly s is o f re tu rn o n IT in v e s tm e n t. J H ealthc Eng 2 0 1 1 ; 2 : 4 3 - 5 4 9 . P o o n E G , K e o h a n e C A , Yoon C S , e t al: E ffe c t o f b a r-c o d e te c h n o l o g y o n th e s a fe ty o f m e d ic a tio n a d m in is tra tio n . N E n g l J M e d 2 0 1 0 ; 3 6 2 :1 6 9 8 -1 7 0 7 1 0 . W o n g D H , G a lle g o s Y, W e in g e r M B , e t al: C h a n g e s in in te n s iv e c a re u n it n u rs e ta s k a c tiv ity a fte r in s ta lla tio n o f a th ird -g e n e ra tio n in te n s iv e c a re u n it in fo rm a tio n s y s te m . C rit C are M e d 2 0 0 3 ; 3 1 : 2 4 8 8 - 2 4 9 4 1 1 . F ahy B G , K e tz le r JT: Im p le m e n ta tio n o f a h a n d h e ld e le c tro n ic p o in to f-c a re b illin g s y s te m im p ro v e d e ffic ie n c y in th e c ritic a l c a re unit.
J Intensive C are M e d 2 0 0 7 ; 2 2 : 3 7 4 - 3 8 0 1 2. H a lp e rn N A : In n o v a tiv e d e s ig n s fo r th e s m a rt IC U : P a rt 1: F ro m in itia l th o u g h ts to o c c u p a n c y . C h e s t 2 0 1 4 ; 1 4 5 : 3 9 9 - 4 0 3 1 3 . G rie g e r D L, C o h e n S H , K ru sch D A : A p ilo t s tu d y to d o c u m e n t th e return on in v e s tm e n t fo r im p le m e n tin g an a m b u la to ry e le c tro n ic h e alth re c o rd a t an a c a d e m ic m e d ic a l ce n te r. J A m C o ll S urg 2 0 0 7 ; 2 0 5 : 8 9 - 9 6 1 4 . P a s to re s S M , D a k w a r J, H a lp e rn N A : C o s ts o f c ritic a l c a re m e d ic in e .
C rit Care C lin 2 01 2; 2 8 : 1 - 1 0 , v 1 5 . S lig h t SP , F ranz C , O lu g b ile M , e t al: T he R e tu rn o n In v e s tm e n t o f Im p le m e n tin g a C o n tin u o u s M o n ito rin g S y s te m in G e n e ra l M e d ic a lS u rg ic a l U n its . C rit Care M e d 2 0 1 4 ; 4 2 : 1 8 6 2 - 1 8 6 8 1 6 . B ro w n H, T e rre n c e J, V a s q u e z P, e t al: C o n tin u o u s m o n ito rin g in an in p a tie n t m e d ic a l-s u rg ic a l u n it: A c o n tro lle d c lin ic a l trial. A m J M ed 2 0 1 4 ; 1 2 7 :2 2 6 - 2 3 2 17. M ilb ra n d t E B , K e rs te n A, R a h im MT, e t al: G r o w th o f in te n s iv e c a re u n it re s o u rc e u s e a n d its e s tim a te d c o s t in M e d ic a re . C rit C are M ed 2 0 0 8 ; 3 6 :2 5 0 4 -2 5 1 0 1 8 . Z im lic h m a n E, B ro w n H, S h in a r Z , e t al: C o n tin u in g m o tio n s e n s in g te c h n o lo g y as a n u rs in g m o n ito rin g a n d a le rtin g to o l to p re v e n t in -h o s p ita l d e v e lo p m e n t o f p re s s u re u lc e rs . In te rn a tio n a l S o c ie ty fo r Q u a lity in H e a lth C a re A n n u a l M e e tin g . H o n g K o n g , 2 0 1 1
w w w .c c m jo u r n a l.o r g
1953
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
David Shaz, MD Department of Medicine James J. Peters VA Medical Center Bronx, NY; and Department of Anesthesiology and Critical Care Memorial Sloan Kettering Cancer Center New York, NY
eturn on investment (ROI) is an integral component of the complicated process of introducing new tech nologies in critical care. Determining ROI is especially im portant for technologies that are costly, purport to have added values, but may also have negative values, and rely upon a num ber of business-related assumptions (1). Thus, build ing the ROI justification may be quite challenging because the variables involved may not be easily articulated, measured, or monetized (2-6). Costs are identified within confusing catego ries (i.e., direct, indirect, variable, and missed opportunity) and the num ber of added values is potentially endless. These may include advancing quality of care, standardizing tech nologies, improving workflow, throughput, efficiencies, staff teaching and patient safety, avoiding errors, enhancing record keeping, improving job satisfaction, meeting national m an dates, and opening up novel pathways to attract new patients or research projects. Potentially "negative" values (i.e. adjust ment to new care models and resistance to change) should also be monetized and factored into the ROI. Finally, assumptions built into the ROI may also be subject to unpredictable per turbations. For example, projected reimbursements may be decreased because of changes in billing rules (7). So the dilemma on the part of the champion of the new technology, in this case, the intensivist, is determining which components of the ROI need to be stressed. O f great import, the intensivist must figure out how the ROI variables will be measured
R
*See also p. 1862. Key Words: critical care; healthcare informatics; return on investment Supported, in part, by the Department of Anesthesiology and Critical Care at Memorial Sloan Kettering Cancer Center, NY. Dr. Halpern served as a board member for Pronia Medical, Instrumentation Lab, and Cardiopulmonary. Dr. Shaz has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0000000000000422 1952
w w w .c c m jo u r n a l.o r g
and ultimately quantified and reported. ROI calculations are rela tively straightforward when there is clear cause and effect (2, 8), but in our elaborate ICU world, the ROI arithmetic is much more complex (1). Even the learning curve and resources necessary to introduce new technologies must be factored into the cost (9). And how much improvement over current practice (i.e. 5%, 25%, or 50%) represents "success" within the ROI (10,11)? Hospitals commonly control the introduction of new technologies, particularly expensive and widely used devices, through a product evaluation and/or clinical device committee. Thus, the project champion needs to get involved in commit tee-based presentations, politicking, campaigning to get buyin from prospective users, and obtaining fiscal support. Since many new devices are actually healthcare informatics plat forms, the hospital’s informatics and biomedical engineering teams must be intimately involved to ensure that the project can be supported (12). This commonly involves an analysis of exist ing networks, interfaces, and middleware. Furthermore, new technologies should be assessed in the hospital’s simulation laboratory and then trialed in a controlled clinical pilot, hope fully vendor sponsored, with well-defined and measurable goals (13). The ROI cost projections should also factor in both the current and future costs of the informatics components (net work, software upgrades, yearly licenses, and vendor support). ROI projections in critical care may target cost savings through hoped for decreases in the ICU length of stay (LOS). Importantly, the ICU LOS data must differentiate between high acuity ICU days and extended stay lower acuity ICU days due to the inability to transfer clinically improved ICU patients to the wards. The ROI m ust also select from one of two m eth ods of calculating ICU and ward costs per day. The first uses previously published national average ICU and ward costs per day (14) as proxies representing the study hospital costs. In the second, the ROI process establishes the actual costs for each ICU and ward day using the hospital’s cost/charge database. The former uses macroeconomic data that may not be appli cable to the study hospital and assigns identical average costs per day for each day; whereas the latter is more preferable as the daily costs are directly calculated and relevant. When the intensivist is presenting the ROI proposal, it is very important to think about the “next day,” whenever that next day is. For example, if the new technology performs as predicted, and the assumptions inherent in the project are realized and the ROI works out, everything is great! On the other hand, what if the ROI does not come to pass as promised because “stuff” happens? Who suffers the consequences especially in a costly project with an overly exaggerated ROI? Therefore, the ROI calculus must be grounded in reality. It is important not to oversell the ROI, no matter how excited the intensivist feels about the project. Impor tantly, do not rely upon the vendor to provide all the background August 2 0 1 4 - Volume 42 • Number 8
Editorials
cost data and the many savings that will undoubtedly accrue. Remember, as cynical as this sounds, the main imperative for the vendor is to sell their merchandise. In this issue of Critical Care Medicine, Slight et al (15) pres ent a technology-based ROI study. Their ROI analysis is predi cated upon a previously published pre- and postinterventional trial of a continuous noninvasive m onitoring and alert system for heart and respiration rates and patient movement (16). This study was conducted on ward-based medical-surgical patients in a single com m unity hospital. Patients with alerts were either transferred to the ICU or remained on the ward. The intervention group (noninvasive m onitor) had shorter ICU and/or hospital lengths of stay than the control group (no intervention) and a significant decrease in code blue events (16). The largest ROI was observed in reduced LOS primarily for ward patients and at a lower level for ICU transfers. This study has great value in that it presents an in-depth look at ROI methodology using a healthcare informatics platform. Impor tantly, the investigators approach inpatient and ICU care and costs as one continuum. The authors delve into the challenging arena of obtaining start-up and ongoing informatics type costs includ ing hardware, software licenses, infrastructure, staff training, and ongoing operations and warranties. Benefits within the ROI calcu lations were tracked using hospital LOS for patients who remained on the ward, and hospital and ICU LOS for patients transferred from the ward to the ICU. The authors did not calculate their own ward and ICU daily costs; they proxied these costs using data from a prior study of Medicare beneficiaries (17). Potential for decreased pressure ulcers was also monetized. The authors incorporated both optimistic and pessimistic assumptions within a sensitivity analysis and present both liberal (total hospital LOS) and conservative (last day in ICU and hospital) models of cost savings so as not to over sell the ROI. Additionally, they factored cost indexing, inflationary rates, and break-even points into this 5-year study. There are some challenges associated with this study. First, the reader must rely upon the findings of a previously pub lished study in another journal (16) and data presented at an international meeting (18) to buy into the efficacy of the non invasive m onitoring device. Furthermore, the implication that a technology applied to non-ICU patients can be used in ROI calculations involving the ICU may represent a leap of faith that the ICU stay was actually impacted by the device. Addi tionally, as the authors note, many of the intangible elements of cost were not included, that is, workflow changes, decreases in nurses' exposure to alarm fatigue, benefits of early alerts for rapid response team activations, and less hands-on monitoring of the inpatient. Furthermore in this study, the most striking finding of a dramatic reduction in code blue events is not even addressed in the ROI. It is also quite difficult to make inter-institutional general izations regarding the ROI associated with healthcare infor matics platforms. This is due to the lack of comparability between informatics infrastructures, technologic capabilities,
Critical Care Medicine
and support among facilities. In addition, the level of interac tions between computerized alerts, rapid response teams, and front-line nursing differ significantly among hospitals. In conclusion, the authors lay out a very comprehensive ROI roadmap for new technology. But at the same time, this study demonstrates that even with a well-defined and sophisti cated understanding of the ROI process, in the end, the authors still “bet the house” on that well-trodden and easily measurable variable, LOS.
REFERENCES 1. P a s to re s S M , H a lp e rn N A : A c q u is itio n s tra te g ie s fo r c r itic a l c a re te c h n o lo g y . C rit C are C lin 2 0 0 0 ; 1 6 : 5 4 5 - 5 5 6 2. S a c h d e v a R C : M e a s u rin g th e im p a c t o f n e w te c h n o lo g y : A n o u tc o m e s -b a s e d a p p ro a c h . C rit C are M ed 2 0 0 1 ; 2 9 : N 1 9 0 - N 1 9 5 3 . W a n g SJ, M id d le to n B, P ro s s e r LA, e t al: A c o s t-b e n e fit a n a ly s is o f e le c tro n ic m e d ic a l re c o r d s in p rim a ry ca re . A m J M e d 2 0 0 3 ; 1 1 4 :3 9 7 - 4 0 3 4. H a rd y PA: G e ttin g a re tu rn o n in v e s tm e n t fro m s p e n d in g c a p ita l d o l la rs o n n e w b e d s . J H e a lth c M anag 2 0 0 4 ; 4 9 : 1 9 9 - 2 0 5 5. O rio l N E , C o te PJ, V ava sis AP, e t a l: C a lc u la tin g th e re tu rn o n in v e s t m e n t o f m o b ile h e a lth c a re . B M C M e d 2 0 0 9 ; 7 :2 7 6. M a n s fie ld J, J a rre tt S : U s in g s m a rt p u m p s to u n d e rs ta n d a n d e v a lu a te c lin ic ia n p ra c tic e p a tte rn s to e n s u re p a tie n t sa fe ty . H o sp Pharm 2 0 1 3 ; 4 8 :9 4 2 -9 5 0 7. C a s te lla n o s I, S c h u ttle r J, P ro k o s c h H U , e t al: D o e s in tro d u c tio n o f a P a tie n t D a ta M a n a g e m e n t S y s te m (P D M S ) im p ro v e th e fin a n c ia l s itu a tio n o f an in te n s iv e c a re u n it? B M C M e d Inform D e cis M ak 2 0 1 3 ; 1 3 :1 0 7 8. A le m i F, Z a rg o u s h M , O a k e s JL Jr, e t al: A s im p le m e th o d fo r c a u s a l a n a ly s is o f re tu rn o n IT in v e s tm e n t. J H ealthc Eng 2 0 1 1 ; 2 : 4 3 - 5 4 9 . P o o n E G , K e o h a n e C A , Yoon C S , e t al: E ffe c t o f b a r-c o d e te c h n o l o g y o n th e s a fe ty o f m e d ic a tio n a d m in is tra tio n . N E n g l J M e d 2 0 1 0 ; 3 6 2 :1 6 9 8 -1 7 0 7 1 0 . W o n g D H , G a lle g o s Y, W e in g e r M B , e t al: C h a n g e s in in te n s iv e c a re u n it n u rs e ta s k a c tiv ity a fte r in s ta lla tio n o f a th ird -g e n e ra tio n in te n s iv e c a re u n it in fo rm a tio n s y s te m . C rit C are M e d 2 0 0 3 ; 3 1 : 2 4 8 8 - 2 4 9 4 1 1 . F ahy B G , K e tz le r JT: Im p le m e n ta tio n o f a h a n d h e ld e le c tro n ic p o in to f-c a re b illin g s y s te m im p ro v e d e ffic ie n c y in th e c ritic a l c a re unit.
J Intensive C are M e d 2 0 0 7 ; 2 2 : 3 7 4 - 3 8 0 1 2. H a lp e rn N A : In n o v a tiv e d e s ig n s fo r th e s m a rt IC U : P a rt 1: F ro m in itia l th o u g h ts to o c c u p a n c y . C h e s t 2 0 1 4 ; 1 4 5 : 3 9 9 - 4 0 3 1 3 . G rie g e r D L, C o h e n S H , K ru sch D A : A p ilo t s tu d y to d o c u m e n t th e return on in v e s tm e n t fo r im p le m e n tin g an a m b u la to ry e le c tro n ic h e alth re c o rd a t an a c a d e m ic m e d ic a l ce n te r. J A m C o ll S urg 2 0 0 7 ; 2 0 5 : 8 9 - 9 6 1 4 . P a s to re s S M , D a k w a r J, H a lp e rn N A : C o s ts o f c ritic a l c a re m e d ic in e .
C rit Care C lin 2 01 2; 2 8 : 1 - 1 0 , v 1 5 . S lig h t SP , F ranz C , O lu g b ile M , e t al: T he R e tu rn o n In v e s tm e n t o f Im p le m e n tin g a C o n tin u o u s M o n ito rin g S y s te m in G e n e ra l M e d ic a lS u rg ic a l U n its . C rit Care M e d 2 0 1 4 ; 4 2 : 1 8 6 2 - 1 8 6 8 1 6 . B ro w n H, T e rre n c e J, V a s q u e z P, e t al: C o n tin u o u s m o n ito rin g in an in p a tie n t m e d ic a l-s u rg ic a l u n it: A c o n tro lle d c lin ic a l trial. A m J M ed 2 0 1 4 ; 1 2 7 :2 2 6 - 2 3 2 17. M ilb ra n d t E B , K e rs te n A, R a h im MT, e t al: G r o w th o f in te n s iv e c a re u n it re s o u rc e u s e a n d its e s tim a te d c o s t in M e d ic a re . C rit C are M ed 2 0 0 8 ; 3 6 :2 5 0 4 -2 5 1 0 1 8 . Z im lic h m a n E, B ro w n H, S h in a r Z , e t al: C o n tin u in g m o tio n s e n s in g te c h n o lo g y as a n u rs in g m o n ito rin g a n d a le rtin g to o l to p re v e n t in -h o s p ita l d e v e lo p m e n t o f p re s s u re u lc e rs . In te rn a tio n a l S o c ie ty fo r Q u a lity in H e a lth C a re A n n u a l M e e tin g . H o n g K o n g , 2 0 1 1
w w w .c c m jo u r n a l.o r g
1953
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
