Professional Documents
Culture Documents
Robert Ohsfeldt
C
ARDIAC ARREST RESULTS
EXECUTIVE SUMMARY numerous deaths and seri- Delbanco, 1991; Kause et al.,
Cardiac arrest results in numer-
ous morbidities in hospital 2004). Reports indicate the quality
ous deaths and serious mor- settings every year. Within of cardiopulmonary resuscitation
bidities in hospital settings pediatric hospitals, children, who is lacking, thus impairing patient
every year. are not in the intensive care unit safety outcomes (Abella et al.,
Rapid response teams (RRT), and experience heart failure, are 2005). In addition, costs per quali-
consisting of interdisciplinary not able to be resuscitated 50% to ty of life year gained are expen-
team members, can be called 67% of the time (Nowak & Brilli, sive. A cost-effectiveness study
prior to a patients need for 2007). A study of cardiopulmon- conducted by Ebell and Kruse
resuscitation during cardiac ary arrest in a hospital in Australia (1994) found that cost per quality-
arrest. revealed approximately 73% of adjusted life year (QALY) for car-
Determining the effectiveness children survived the initial car- diopulmonary resuscitation was
of these teams has been a con- diac arrest resuscitation but only $61,000 in 1991 U.S. dollars, which
cern to researchers as well as 34% survived for 1 year after the equals almost $100,000 per QALY
to the hospitals implementing arrest (Tibballs & Kinney, 2006). in 2011 U.S. dollars (Bureau of
these teams. Genardi, Cronin, and Thomas Labor Statistics, n.d.).
In this study, total personnel (2008) indicate that less than 20% These studies produce sober-
costs associated with different of adults experiencing cardiac ing evidence concerning the cur-
RRTs were analyzed, and RRT arrest while in the hospital sur- rent manner and cost for care
effectiveness was compared to vive; and an overwhelming major- delivered in our hospitals and
existing code blue or cardiac
arrest teams.
ity of arrests occur after hours of demonstrate a need for interven-
slow deterioration. Several other tions to occur before cardiac arrest
RRTs that shared personnel researchers have pointed to vari- and resuscitation events. To
with the traditional cardiac
arrest team, yet also added
ous antecedents to cardiac arrest, reduce poor outcomes and pro-
new personnel, provided better which if monitored, could allow vide better patient safety, hospi-
care at a reduced cost when intervention to reduce or elimi- tals have attempted to implement
looking at quality-adjusted life nate these preventable cardiac a wide range of innovations design-
years 6 months after cardiac
arrest.
AARON SPAULDING, PhD, MHA, is ROBERT OHSFELDT, PhD, is Professor,
Assistant Professor, Department of Public School of Rural Public Health, Depar-
Health, Brooks College of Health, Univer- tment of Health Policy and Management,
sity of North Florida, Jacksonville, FL. Texas A&M Health Science Center,
College Station, TX.
Annual Hourly
Jobs Country U.S. Equivalent Pay ($) Pay ($) Source
Anesthesiologists United States 218,434.03 105.02 Bureau of Labor Statistics, 2011a
Cardiovascular ICU United States 64,701.03 31.11 O*NET OnLine, 2010e
nurse
Critical Care Nurse United States 64,701.03 31.11 O*NET OnLine, 2010e
Floor Nurse United States 64,701.03 31.11 O*NET OnLine, 2010d
Hospital Chaplain United States 43,590.74 20.96 O*NET OnLine, 2010b
Hospitalist United States 263,908.93 84.17 Leigh et al., 2010
Intensivist or Internal United States 173,278.97 58.46 Leigh et al., 2010
Medicine
Intern United States 48,224.66 14.36 American Medical Association, 2011
Junior Assistant United States 49,637.11 14.78 Ohio State Medical Center, 2011
Resident
Nursing Supervisor United States 69,199.50 33.27 PayScale, 2011
Pharmacists United States 109,995.85 52.88 Bureau of Labor Statistics, 2011b
Physician United States 167,588.30 67.42 Leigh et al., 2010
Physician Assistant United States 87,507.71 42.07 Bureau of Labor Statistics, 2011c
Respiratory Therapist United States 55,910.86 26.88 Bureau of Labor Statistics, 2011e
Security Officer United States 87,146.67 41.9 O*NET OnLine, 2010c
Senior Assistant United States 51,375.67 15.29 Ohio State Medical Center, 2011
Resident
Nurse Consultant England Clinical Nurse
83,071.05 39.94 O*NET OnLine, 2010a
Specialist
ICU Residents Canada ICU Residents 49,637.11 14.78 Ohio State Medical Center, 2011
Emergency Department Australia Emergency 252,585.22 102.48 Leigh et al., 2010
Doctor Department
Physician
ICU Consultant Australia Attending Physician 167,588.30 67.42 Leigh et al., 2010
ICU Nurse Australia ICU Nurse 64,701.03 31.11 O*NET OnLine, 2010e
ICU Physician Australia Internal Medicine 173,278.97 58.46 Leigh et al., 2010
ICU Registrar Australia ICU Fellow 58,822.63 17.51 Ohio State Medical Center, 2011
Medical Registrar Australia Internal Medicine 58,822.63 17.51 Ohio State Medical Center, 2011
Fellow or Chief
Resident
Receiving Medical
Australia Junior Attending 167,588.30 67.42 Leigh et al., 2010
Unit Fellow
Registered Nurse Australia Registered Nurse 57,996.68 27.88 Bureau of Labor Statistics, 2011d
Senior Intensive Care
Australia Senior ICU nurse 64,701.03 31.11 O*NET OnLine, 2010e
Nurse
Senior Nurse Australia Senior Nurse 64,701.03 31.11 O*NET OnLine, 2010d
which to base cost of training per members for all code blue teams Sensitivity analysis accounted
member in either team (Campello reported in the study. for time of treatment, variance in
et al., 2009; Dacey et al., 2007). In Effectiveness is reported as team member costs, training, pop-
one study, the combined training cost per QALY 6 months after car- ulation risk, utility, and imple-
cost for the RRT was $50,000 diac arrest, and is based on the mentation costs. Particular em-
while airway and critical care average age of the individuals phasis was placed on sensitivity
training was an additional within the hospital. QALYs for the analysis for training since these
$60,000 in 2007 dollars (Dacey et populations in the study are cal- values are not well reported in the
al., 2007). Cost of training a car- culated using data published in literature and the proposition that
diac arrest team was estimated to the US Norms for Six Generic variable costs are a driver of the
be $175,425 in 1992 dollars (Vrtis, Health-Related Quality of Life overall cost effectiveness of these
1992b). Inflating training costs for Indexes from the National Health types of interventions.
both teams to 2011 dollars results Measurement Study (Fryback et
in cardiac care team training costs al., 2007). QALY measures associ- Results
of $279,414 per team and RRT ated with survivors of cardiac As expressed in Table 3, the
training costs of $118,554 per arrest were obtained from Nichol shared personnel and completely
team. When individuals are mem- and colleagues (1999) study on new RRT models demonstrated
bers of both the RRT and code quality of life for survivors of car- effectiveness in reducing the num-
blue team, the overall costs for diac arrest. Both QALY measures ber of cardiac arrests as compared
training are calculated as the car- used in this study utilized the to the standard care. To reiterate,
diac arrest team cost plus the RRT Health Utilities Index Mark 3 sys- standard care involves the use of
staff training cost which equals tem (HUI3). The tree diagram used only cardiac arrest or code blue
$334,127 combined. Finally, the to determine the cost effectiveness teams, and as such, is a single-
number of individuals who are of these teams is presented in Figure tiered system. The other strategies
present on each team is a result of 1. This cost-effectiveness analysis provide an additional layer of sup-
the average number of members was conducted using TreeAge Pro port for those who might experi-
for each branch. The standard care Software (Williamstown, MA). ence a cardiac arrest. The results
arm is the average number of of the cost-effectiveness model
Cardiac Arrest
PR_SCCA
Standard Care
No Cardiac Arrest
#
Cardiac Arrest
Cardiac Arrest
Table 3.
Cost-Effectiveness Rankings
Incremental Cost/
Incremental Incremental Incremental Average Cost
Strategy Effectiveness Effectiveness Cost Cost Effectiveness Dominance Effectiveness
Shared 0.38499845 $126,805.38 $329,365.96
Personnel
Completely 0.384998194 ($14,721,492,136.16) $130,572.28 $3,766.90 ($14,721,492,136.16) Dominated $339,150.38
New RRT
Standard 0.384926381 ($2,117,554,026.98) $279,414.99 $152,609.60 ($2,117,554,026.98) Dominated $725,892.01
Care
RRT Same as 0.384997116 ($151,936,398,197.13) $329,417.50 $202,612.11 ($151,936,398,197.13) Dominated $855,636.27
Code Blue Team
Incremental Cost/
Code Blue Team Incremental Incremental Cost-Effectiveness
Training Cost Strategy Effectiveness Ratio Dominance
$150,000.00 Shared Personnel $319,441.83
Completely New RRT $324,697.31 $(7,907,186,274.33) Dominated
Standard Care $389,686.61 $(374,864,623.67) Dominated
RRT Same as Code Blue Team $855,636.27 $(154,801,552,697.21) Dominated
$200,000.00 Shared Personnel $323,276.07
Completely New RRT $330,281.34 $(10,539,934,078.16) Dominated
Standard Care $519,581.58 $(1,048,163,091.97) Dominated
RRT Same as Code Blue Team $855,636.27 $(153,694,583,128.97) Dominated
$250,000.00 Shared Personnel $327,110.32
Completely New RRT $335,865.37 $(13,172,681,881.99) Dominated
Standard Care $649,476.54 $(1,721,461,560.27) Dominated
RRT Same as Code Blue Team $855,636.27 $(152,587,613,560.73) Dominated
$300,000.00 Shared Personnel $330,944.57
Completely New RRT $341,449.40 $(15,805,429,685.82) Dominated
Standard Care $779,371.51 $(2,394,760.028.57) Dominated
RRT Same as Code Blue Team $855,636.27 $(151,480,643,992.49) Dominated
$350,000.00 Shared Personnel $334,778.82
Completely New RRT $347,033.43 $(18,438,177,489.65) Dominated
RRT Same as Code Blue Team $855,636.27 $(150,373,674,424.25) Dominated
Standard Care $909,266.48 $(3,068,058,496.88) Dominated
revealed teams who shared per- have little to no impact (see Table have proposed that training does
sonnel between the RRT and the 4). However, when training costs in fact provide the mechanism for
code blue team were most cost for RRTs were adjusted, there were RRT success (Campello et al.,
effective with an expected cost of slight changes in the incremental 2009). This study supports that
$329,365.96 for each QALY cost effectiveness and all strate- argument to some extent, but adds
gained. This team composition gies remained dominated by a caveat which demonstrates team
dominated all other options in the teams who shared personnel bet- composition plays a role in effec-
model (see Table 3). ween the RRT and the code blue tiveness as well. The considera-
RRTs/EMTs comprised of the team. When adjusting for training tion of team composition and the
same members as the code blue or costs for code blue/cardiac arrest impact different teams have on
cardiac arrest team were more teams, changes only occurred patient safety and patient out-
expensive than the standard care when code blue training costs comes seem to be an obvious over-
using the base case estimates. A reached $350,000, at which point sight. This is particularly true in
sensitivity analysis concerning standard care becomes the least light of the amount of team train-
total team training costs, time of viable option. ing, team satisfaction, team out-
care, personnel costs, and differ- come, and team culture studies
ences in health state utility pro- Discussion which exist in management and
vides evidence these results are Previous arguments concern- health care. How can we decide to
somewhat dependent upon train- ing the effectiveness of RRTs have implement teams of skilled per-
ing costs, while the other variables focused around training costs, and sonnel to achieve specific tasks