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A Strategy for Inpatient Integration. Terry Horton, MD, FACP Delaware Valley Node September 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

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a strategy for inpatient integration

A Strategy for Inpatient Integration

Terry Horton, MD, FACP

Delaware Valley Node

September 21, 2010

hospitals inpatient services aggregate the highly disordered
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
Hospitals have an Emerging Imperative

Need to Improve:

  • Safety
  • Health care costs
  • Joint Commission compliance
hospitals need best methods tools to
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
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***

Tx gap

* 2004-2005 NSDUH data

** Wright et al. 2007

*** Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health, 2007

delaware s primary hospital system
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
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
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
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
Outcomes: Improved Safety
  • No Sentinel Events since launch
  • Significant reduction of submitted

cases to DOM

  • No cases to date associated with over-treatment
length of stay
Length of Stay

Protocol launch

project engagement
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
Project Engagement: Partnering with DPCI/Aetna

Delaware Physicians Care Inc, May, 2010

ctn opportunities for inpatient based research
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