Capnography Use Saves Lives & Money

Most prehospital providers don’t consider the delivery of EMS a business. They feel they’re in the “business” of saving lives, not money. But in these current economic conditions, EMS managers are being forced to evaluate cost-saving measures for their agencies. One common dilemma is how to maximize care at minimum cost. Another is making necessary budget cuts without reducing patient services. The solution: Use a cost-benefit analysis.

A cost-benefit analysis can help you determine which alternative is likely to provide the greatest return for a proposed investment. The goal of any system is to determine how well, or how poorly, a planned action will turn out. Cost-benefit analysis relies on the addition of positive factors and the subtraction of negative ones to determine a net result. It’s also frequently referred to as “running the numbers.”(1)

This type of analysis was originally used by managers to make monetary decisions regarding large-scale business projects. It can be effective, however, as an informal approach to making many economic decisions. In the early 1960s, it was extended to the assessment of the relative benefits and costs of health-care equipment and services.

The key to using cost-benefit analysis in EMS is to evaluate each service provided. You must take into account all potential costs and associated benefits the patient receives. The following is a basic example of how cost-benefit analysis can be used effectively in EMS as a management, budgetary and quality-improvement tool.

Capnography: A Cost-Benefit Analysis
The evaluation of the benefits vs. the costs of using capnography can be categorized into two primary areas:
1. Benefit vs. cost of providing appropriate treatment; and
2. The avoidance of medical malpractice lawsuits/settlements.

Three cases are presented here to illustrate the effect of proper capnography use and a potential cost-benefit analysis of how capnography could affect other EMS treatment modalities and supplies that could be involved in the care of patients managed by EMS crews. Except where indicated, all costs are for a single treatment.   

Special Considerations:
1. It’s impossible to definitively state how every patient will respond to care for the conditions presented and what additional care would actually be required. Therefore, the cases presented make patient response-to-care assumptions to simply illustrate possible treatments and expendable item expenses to demonstrate the potential cost-benefit analysis of capnography use.
2. For simplicity, the costs presented in this article for capnography use ($10 per usage) are the disposable costs that would be incurred by a service in addition to the cost of adding capnography (estimated at $3,000) to each cardiac monitor. If you wanted to, you could also factor in the hardware cost, amortized over time and by annual usage and factored into your cost-benefit analysis.

Example: If you amortized the $3,000 per unit capnography add-on cost over five years ($3,000/5 years = $600/year), and by 700 uses per year (less than two uses per day by each), you could factor in a per-usage equipment amortization cost of $0.86 per use ($600/700 uses = $0.86/use).

Patient 1
A COPD patient with confirmed wheezing
“¢Treatment: Administer albuterol and Atrovent via updraft.
“¢Cost: $3.25—5, (see Table 1).
“¢Results: Capnography assessment shows a reversal of the initial shark-fin waveform and normalization of end-tidal carbon dioxide (EtCO2).
“¢If the patient’s condition is improved, minimal additional care would be required. However, if the patient is still in distress despite normalized EtCO2, further assessment and treatment would be initiated.
“¢Discussion: Without capnography, EMS protocols could require further treatment that might be unnecessary. Continuing care with the use of Solu-Medrol and continuous positive airway pressure (CPAP)–a typical protocol–would add $41—107 to this patient’s treatment cost. The use of capnography ($10 disposable cost), therefore, provides a potential cost savings of $31—97.

Patient 2
A heroin overdose patient with a respiratory rate of 6
“¢Treatment: Assist the patient’s ventilations with a bag-valve mask (BVM) and administer naloxone to reverse the actions of the heroin.
“¢Cost: $27.50—50, (see Table 2, p. 12).
“¢Results: The capnography assessment reveals adequate ventilation with normalizing EtCO2.
If the patient’s airway is secure and no other clinical concerns are presented that dictate advanced airway use, you may not need to intubate this patient.
“¢Discussion: If the patient were intubated with an endotracheal (ET) tube or alternative airway, such as a laryngeal mask airway (LMA) or pharyngo tracheal lumen (PtL), an additional $9—62.25 would be added to the patient’s treatment cost. Therefore, the use of capnography could potentially present a cost savings of $52.25.

Patient 3
Acute inferior wall myocardial
infarction patient with a BP of 80/60
“¢Treatment: Initial IV fluid bolus of 300 mL.
“¢Cost: $9.50—21, (see Table 3).
“¢Results: The capnography assessment after the first fluid challenge shows an improvement in the patient’s EtCO2 (from 22 to 28). After the administration of a second fluid challenge (no additional cost involved), the capnography assessment shows an improvement in EtCO2 (from 28 to 35).
“¢Note: Capnography alone won’t dictate whether further care or medications are necessary to stabilize this patient. If the patient’s blood pressure and overall condition aren’t improved after the fluid boluses, additional care may be necessary. However, for this simulated patient, we’re assuming no additional care was necessary to illustrate what your cost savings would be.
“¢Discussion: Continuing with dopamine therapy would add $18—28 to the cost of the patient’s treatment. Therefore, the use of fluid challenges in conjunction with capnography provides a potential cost savings of $8—18.
Having the assessment capability of capnography to determine that basic therapies are sufficient and additional therapy isn’t needed can result in substantial cost savings for your service and the patient.

Medical Malpractice Costs
In 2006, at least 30 EMS lawsuits reached the Court of Appeals. A significantly higher number, probably in the hundreds, were decided at trial, and even more were settled out of court.(2)

The most common causes for EMS lawsuits are negligent vehicle operation and improper performance of medical procedures. Juries frequently award millions of dollars to patients, and legal fees are typically hundreds of dollars per hour, producing a significant unbudgeted expenditure to an agency. Therefore, capnography is one piece of clinical backup that can assist you in avoiding lawsuits.

How does capnography help in this area?

One of the most frequent EMS lawsuits involves undetected esophageal intubations. If the ET tube is improperly inserted into the esophagus and this error isn’t recognized and corrected expediently, the result is a devastating hypoxia that causes severe brain injury and, ultimately, death. Continuous monitoring of capnography is the standard of care for detecting esophageal intubations, as well as for detecting subsequent dislodgement of ET tubes.(3)

Settlements for injury and wrongful death resulting from undetected misplaced ET tubes are often in the multimillion-dollar range.

Here are some recent case examples:
“¢In Ohio, a medical malpractice suit was filed against an EMS agency after the death of a 2-year-old boy. The patient died following a hospital transfer during which his ET tube became dislodged but wasn’t detected. The final settlement wasn’t made public.
“¢In Texas, a 41-year-old female suffered severe brain damage and died following an undetected esophageal intubation. Capnography wasn’t in use. The case settled out of court for $500,000.
“¢A Florida-based air ambulance service was sued when a 58-year-old female suffered severe brain damage and died when an ET tube became dislodged and was undetected. Capnography wasn’t in use. The case was settled out of court for an undisclosed sum.

Another common cause of EMS lawsuits is injuries or deaths resulting from emergency vehicle crashes. In 1997, more than 15,000 accidents related to emergency calls occurred with emergency vehicles in the U.S. resulting in 8,000 injuries, 500 fatalities and millions of dollars in liability claims and vehicle repairs.(4) One area in which these types of emergency transport crashes can be reduced is by not transporting nonviable cardiac arrest patients.

Civil rules, administrative concerns, medical insurance requirements and even reimbursement enhancement have frequently led to requirements that indicate the transport of all cardiac arrest patients to a hospital or emergency department. If these requirements are nonselective, they’re inappropriate, futile and ethically unacceptable. Cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems.(5)

One component of cardiac arrest termination protocols is a sustained EtCO2 of less than 10 mmHg, often secondary to asystole present after two rounds of cardiac arrest drugs.(5) The continuous monitoring of capnography can confirm a EtCO2 reading of less than 10 mmHg, along with your protocols and other clinical assessment parameters, and assist you in terminating resuscitative efforts and prevent unnecessary, and often dangerous, emergency transport.

Another potential lawsuit involves the patient who’s been sedated or physically restrained. Restraint lawsuits are generally related to brain injury or death from “positional asphyxia,” and in the sedated patient, from hypoventilation hypoxia.

The use of continuous capnography to monitor these patients can assist your crews in reducing the chance of missed episodes of apnea or respiratory distress due to patient positioning of restraints. EMS providers alerted to the fact that a patient is hypoventilating could enable them to adjust restraints, reposition the patient or reduce or stop sedation long before significant hypoxia occurs.

Other EMS lawsuits involve the delivery of inappropriate treatment or the failure to provide appropriate treatment. Capnography cost-effectively provides assessment information that guides treatment in a variety of common EMS emergencies, including respiratory emergencies, metabolic emergencies and shock.

Providing quality patient assessment and care are our primary goals. Reducing service costs, maximizing the use of limited financial resources and avoiding lawsuits are secondary–but important–goals. Capnography is a powerful clinical tool that, when used appropriately and in conjuction with a thorough, systematic patient assessment can assist your service is achieving each goal, improving patient care and enabling your service to operate in an efficient and cost-effective manner.

Disclosure: The author has completed contract work for Medtronic/Physio Control Corporation, a manufacturer that utilized Oridion capnography technology in their cardiac monitors.

This article originally appeared in the December 2010 JEMS supplement “Measuring Life & Breath” as “Positive Justification: A cost-benefit analysis of capnography use can prove value to patients & your budget.”

1. Reh JF: Cost Benefit Analysis.
2. Weaver J. Surviving a Lawsuit. EMS World.
3. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;45:497—503.
4. National Aeronautics and Space Administration. NASA to Test Emergency Traffic Vehicle in Monrovia.
5. American Heart Association. Part 8: Adult Advanced Cardiovascular Life Support. Circulation. 2010;122:S729—767.

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