Prolonged ICU Stay in Hospital: Loss or Gain? The Other Side of the Story

Intensive care units (ICU) are the most expensive sections within a hospital. ICU is a place which is quite resource intensive and costs make up to 20-30 per cent of all hospital costs. It accounts for 10 per cent of all hospital beds and 20-25 per cent of the hospital revenue. However, it’s difficult to establish cost-effectiveness in a health system like India which is not only multi-layered but also multi-dimensional. But we can look at economic efficiency or an alternative approaches like partnership for hospitals by integrating home healthcare model, which in turn generates more revenue to the hospitals and improve patient experience and quality of life.                                           

Implications of Prolonged Hospital ICU-LOS (Length of Stay) 

1. Affect Quality of Life: Studies suggest longer ICU stay is associated with muscle weakness and physical impairment. ICU puts emotional burden on patients where pain, anxiety and agitation are important stress factors for many critically ill patients. ICU also have significant subsequent health-related impact on overall quality of life later. 
2. Reduction in Revenue to Hospital:According to a study published in American Journal of Critical Care, it has been estimated that between 2% and 11% of critically ill patients require a prolonged stay in ICU, accounting for 25–45% of total ICU days and a significant proportion of resources. As such, the intensive care unit (ICU) takes a significant proportion of the total healthcare cost, and therefore patients with prolonged ICU length of stay (LOS) can have serious cost implications. 
3. Increase Risk of Hospital-Acquired Infections and Re-admissions: It has been reported that the incidence of nosocomial or health care-associated infections (HAIs) in the intensive care unit (ICU) is about 2 to 5 times higher than in the general in-patient hospital population. The increased morbidity and mortality associated with HAIs in the ICU is a matter of serious concern today. In several studies, the mortality of patients with ICU admissions lasting 14 days or longer was estimated to be nearly 50%. Serious medicolegal issues also arise in this context, since the patient or their families sometimes blame the hospital staff for the infection and demand compensation. 

It has been reported that 5-8% of overall hospital re-admissions are due to care not taken in the post-operative period. Hospital readmissions increase cost two times. It will also increase:

• Monetary  
• Bad publicity to hospitals / clinician
• High claims
• Patient dissatisfaction 

Hospital-Homecare Partnership Provides a Solution Needed 

The solution actually lies in making the transition, this partnership model is just an extension to the hospital facilities being offered. Undisputedly, home environment gives more comfort, familiarity, personalized care which allows patients to become more independent and relaxed. Also, as we Indians give foremost importance to family, many patients prefer spending time or convalescing at home in case of chronic illnesses or in post-operative phase. It also reduces stress and anxiety and provide a place which hasten the recovery process thus improve quality of life. 

Some of the studies which reinforce these facts and tells us the potential value of such partnership are given below: 

• Home care setting improves patient satisfaction. According to a randomized controlled trial of terminally ill patients in US, those who received in-home palliative care from an interdisciplinary team were more satisfied with care, more likely to die at home, less likely to visit emergency department, less likely to be re-admitted to hospital and had 33% lower health care costs when compared with patients who receive usual care. Another study suggests clinical benefits, including a decrease in dyspnoea and anxiety and improvements in sleep and spiritual well-being. 

• Homecare partnership also helps to generate more revenue to the hospitals. According to a study by NHS, there was 67% decrease in ALOS in Australia’s hospital in less than a year. By facilitating administration of intravenous antibiotics for chronic patients at home, NHS saved an equivalent of 20 hospital beds in 4 years amounting to a saving of ￡2 million. Analysis of the NHS dataset has identified the opportunity for the health economy to further save ￡1.3-￡1.7bn through the greater utilisation of home healthcare.
• Avalere is one of the studies which was focused on the impact that home health care had on overall Medicare costs and rates of re-hospitalization. Key findings from the study suggests early home health care use saved Medicare $1.71 billion in 2005-2006 where approximately $216 million (about 12.7 percent) of the savings is attributable to as many as 24,000 fewer hospital readmissions. 

• According to an estimate done by a leading Indian home healthcare player, hospitals can increase their Average Revenue per Occupied Bed (ARPOB) as much as 21% by providing combination of hospital stay followed by home healthcare assisted recovery which will not only reduce the risk of infections and rate of re-admissions but also increase compliance rate.  

• Homecare settings also provide better clinical safety and also enhanced recovery due to almost zero cross-infections and lower re-admission rates. According to NHS data, providing home-based chemotherapy for all cancers suggested savings of ￡73 million at the national level. NHS had a nationwide savings of ￡180 million, with an additional potential savings of ￡32 million by avoiding readmissions. 

So to conclude, as the population ages and increases in number and there is rise in chronic disease burden, who would need long-term care. While a shorter stay at ICU may be unavoidable but for those who would require such facilities for much longer time, Home Healthcare finally provides an alternative solution to being an in-patient. This in turn will reduce the financial burden on the hospital, motivating it to further invest in ICUs. It will improve quality of life and lower the cost of treatment for the patient in the long run.