The third team, “Value Attack,” named their pitch “Push to the PO,” to reduce unnecessary administration of IV antibiotics when cheaper, safer oral dosage works equally well, said Dr. Amber Moore, a hospitalist at Beth Israel Deaconess Medical Center in Boston.
Often, Dr. Moore explained, ED patients are put on an IV if an infection is suspected. “Then they come up to the floor, and the patent stays on IV antibiotics longer than they need it,” even after infection is ruled out.
IV administration has drawbacks. First it’s expensive, she said. “Levaquin IV is $15, but p.o. is $3. PPI [proton pump inhibitor] is $144 IV but $4 p.o.” And there are other problems such as patients’ pain, having multiple IVs, more nursing care, and more time administering the IV.
The Value Attack’s pitch included enlisting speech and swallowing experts to advise when oral antibiotic doses can substitute. Their idea generated $50,000.
Another team, the “Invaluables,” proposed “Just in time discharge” which would use night hospitalists to discharge patients in the evening, if they’re ready to go home and a ride is available, instead of waiting until morning. Dr. Peter Kaboli, chief of medicine at Iowa City VA Medical Center, said at his hospital, as many as 2 patients of up to 12 discharged a day might be able to go home 15 hours earlier, alleviating boarding in the ED for patients who otherwise wait overnight.
“Our culture is that patients don’t leave after 6 p.m.,” even if they’re ready to go, and a ride is ready, Dr. Kaboli said. He acknowledged the concept is not yet based on evidence, “so we’re kind of sticking our necks out here, but nothing ventured, nothing gained.” The team proposed testing discharges by night shift hospitalists. Their idea was awarded $50,000 by the sharks.
The winning Shark Tank team was the Cost Cutters, who proposed “Standup to Syncope” as their project. Dr. Celene Goetz, a hospitalist at Mount Sinai Medical Center in New York, said all too often, healthy nontrauma patients come into the ED because they fainted, usually because they were dehydrated and called 911, and receive a costly head CT scan and unnecessary radiation exposure.
For many of these patients, taking orthostatic vital signs would rule out CT and reduce admissions, not to mention time in the ED. The problem, she explained in an interview, is that ED physicians don’t do the orthostatic, which requires 5 minutes or more of monitoring the patient’s blood pressure.
“That takes so much of a practitioner’s time, and it’s just easier to order the head CT and put a patient on telemetry,” Dr. Goetz said, noting that ED physicians are often worried about lawsuits from missing a stroke or intracranial hemorrhage.
In a poster presented at the conference, Dr. Goetz reported on 162 patients presenting to the ED with syncope. Of these, 71, or 43.6%, got a head CT, and half of these were inappropriate according to American College of Emergency Physicians’ recommendations. Additionally, “none of the head CTs identified an intracranial bleed or changed management.” Further, “if inappropriate head CTs were not ordered for this group of patients, the hospital could have saved at least $8,680 per year,” Dr. Goetz said.
The “sharks” said this was the best idea, and awarded the winning Cost Cutters $70,000.