transferring patients to a higher level of care · time matters. transferring patients in less than...

Improving Risk-Adjusted Mortality Through Clinical Care Improvement And Documentation

Excellence

Transferring Patients To A Higher Level Of Care

Jeffrey S. Kuo, MD, FACEP, FAAEMMedical Director – Ochsner System Patient Flow Center

• Ochsner Health System Overview

• What provoked “immediate intervention”

• Learning from other systems

• Structuring the command center

• Physician In Lead of Transfers (PILOT)

Improving Risk Adjusted Mortality


Ochsner Health SystemOur Mission is to Serve, Heal, Lead, Educate and Innovate

✓ Ochsner is Louisiana’s Largest Not-For-Profit Health System

✓ In 2018, Served 811,183 Patients From Across Louisiana, Every State, and More 70+ Countries

✓ 15 Owned & Managed Hospitals, 23 Affiliated Hospitals and 2 Specialty Hospitals

✓ 100+ Health Centers and 14 Urgent Care Centers

✓ 3 U.S. News & World Report “Best Hospital” Specialty Category Rankings 2018-19

✓ 1,345 employed and over 3,000 affiliated physicians in over 90 specialties & subspecialties

✓ Largest Private Employer in the State with 25,000+ Employees

✓ 288 medical residents and fellows work in 28 Ochsner-sponsored clinical programs

✓ 700+ Active Clinical Trials

✓ $3.1B in Total Operating Revenue; $5B With Financially Integrated Partners

Ochsner will be a global medical and academic leader who will save and

change lives. We will shape the future of healthcare through our

integrated health system, fueled by the passion and strength of our

diversified team of physicians and employees.

Our Vision

IMPACTING LIVES ACROSS LOUISIANA, THE NATION & THE WORLD

Who We Are Drives What We Do

Ochsner’s Core Values

6March 19, 2019

OHS Hospitals - Owned/Leased

OHS Hospitals - Managed/JOA

OHS Clinics

LEGEND

Ochsner Health System Locations (South East Region)

River ParishesLaPlace, LAManaged

ChabertHouma, LAManaged

Terrebonne GeneralHouma, LA

JOA

OMC - HancockBay St. Louis, MS

Leased

St. Bernard ParishChalmette, LA

Managed

St. Charles ParishLuling, LAManaged

St. Tammany ParishCovington, LA

JOA

Slidell MemorialSlidell, LA

JOA

OMC - BRBaton Rouge, LA

Owned

OMC - KennerKenner, LA

Owned

OMC - NSSlidell, LA

Owned

OMC - WestbankGretna, LA

Owned

OMC - St. AnneRaceland, LA

Leased

OMC - Jeff HwyNew Orleans, LA

Owned

OMC - BaptistNew Orleans, LA

Owned

Statewide Ochsner Health System & Network

Financially Integrated

Affiliated

LEGEND

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCILn26-5kMgCFYmfgAod9ToM1A&url=http://www.sthfoundation.org/hof&psig=AFQjCNH9HeZVg8zEMXcwZOBanwjF8T5FBg&ust=1443210805275905

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCO3K-dG78MgCFcfZPgod4JQJ9g&url=http://www.mypatientpoint.com/Slidell-Memorial-Hospital&bvm=bv.106379543,d.cWw&psig=AFQjCNHbvgQnkT6bWGoTN5o4lagMAD4Ntg&ust=1446509952361504

• Up to 50 patients holding in Main Campus ED

• Regional Referral Center on gridlock

• Community hospitals on diversion

• 40-60 transfer requests without any facilities accepting

• 22,000 incoming phone calls to RRC in Jan 2018 (avg. 18,000)

Events That Provoked Immediate Intervention

2017-2018 “Flumageddon”

The Ugly Truth

• Capacity wasn’t balanced across the system

• Several community hospitals never held in ED overnight

• Hospitals were transferring out of the ED due to capacity concerns

• Diversion requirements varied substantially from campus to campus

• Many beds were available, just not staffed……………….and no one knew

Regional Referral Center Patient Volume

Transfer Volume: Disposition Indicator

39144686

5268 56256442

8718

1011510689 11173

11925

950 15542351

2627

3609

3998

6405

9363

11725

198

725

1235

1922

2250

198

822

525

600

0

5,000

10,000

15,000

20,000

25,000

30,000

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019P

Accepted Telemed + Phone Consults Facilitated Transfer Free Standing ED-Accepted

5,6363,914

6,8227,976

9,123

12,525

15,036

19,151

22,983

26,500

Connecting Outcomes to Transfer Times

Time matters. Transferring patients in less than 6 hours saves lives.

Risk Adjusted Mortality Index (RAMI) For Transfers From External Facilities

LESS THAN 6 HOURS

5.1%

> 6 HOURS

7.8%

OBSERVED MORTALITY RATE(RAMI NUMERATOR)

LESS THAN 6 HOURS

6.5%

> 6 HOURS

6.2%

EXPECTED MORTALITY RATE(RAMI DENOMINATOR)

LESS THAN 6 HOURS

0.79

> 6 HOURS

1.26

RAMI

Problem Definition & Scope

Problem Statement: Process breakdowns and poor communication/information flow result in patient holds/throughput delays, putting us at risk for poor patient safety, quality, and experience.

• Routine operations require heroic efforts

• Patients wait too long in the ED, resulting to LWBS

• Admitted patients wait too long in the ED for a bed

• Transferred patients wait too long

• ER diversion and bed holds at community hospitals cause transfer delays

• Patients are delayed for days waiting to get to the right level of Post Acute care

• Patients are often discharged late in the day because of delayed Post Acute facility access.

• Patients wait too long to be flexed to a critical care bed or transferred to step down

• Patients are held in ORs and PACU

• Patients clinical risk is elevated due to lack of clinical information

• Patients receive care at locations that are higher in cost than necessary because of difficulties in access

Systems of Poor Patient Flow

• Collaborating with Epic as the IT platform for all patient flow

• Evolution towards centralized, system-wide bed management

• Building a command center to support system patient flow

• Approval for research & development of command centers via site visits

• Funding a “Quarterback”

• Development of standardized system protocols for patient movement including transfer acceptance

Events That Provoked Immediate Intervention

System Leadership Meeting

Learning From Others

• Operational improvements with key players in same room

• 60% improvement in acceptance of transfers

• Ambulance dispatch time improved by 63 minutes

• OR transport delays reduced by 70%

• Command center design is a true science

• Being off-site has advantages

• Patient flow is embedded in culture

• Easy access to data allows for real time analysis

• Optimizing hospital transport and EVS

• Use of a Quality Dashboard

• Internal hotline for DC delays

• QB Model for transfer acceptance





• Patient Flow Center design/build

• Leveraging technology/dashboards

• Culture change




• Chose a location

• Cost, construction needs, timeline

• Decided who needs to be in the room

• Roles and responsibilities for system vs division

• Planned for current and future needs

• Started to plan for colocation

• Alerts and phone calls vs face-to-face communication

• Technology and equipment

Patient Flow Center

Human Resources and Space Design/BuildWorkgroup included representation from:• Bed Planning• RRC• PFC• Flight Care• Telemedicine• IS• FF&E• HR• PILOT

Introducing The Patient Flow Center

Regional Referral Center

Centralized Bed Planning

Hospital Medicine PILOT

Behavioral Health Placement Team

Case Management

Flight/Ground EMS Dispatch

Non-Emergent Transportation Dispatch

Patient Flow Center Administrative Lead

Facility and Hospital Capacity Statistics

Transfer Patient Tracking

Transfer Center PILOT Dashboard

Driving Results With Technology

Original Workflow Automated Workflow

Transfer Center Model

Requesting Provider inputs Transfer Request or Calls RRC

PILOT, RRC RN & Case Mgmt, review case. Acadian alerted of potential transport

RRC & Pilot have MD to MD; accept transfer, enter admit order

PFC House Sup. Assigns Bed

Requesting facility to RRC

RRC to community AC

RRC to potential accepting MD, MD to MD

AC to RRC with bed assignment

RRC to Acadian

RRC to sending facility

AC calls accepting to input admit order

Accepted

Transfers

Telemedicine

Consults

October YTD Volume Comparison

+54%+6%2017:8,785

2018:9,299

2017:3,561

2018:5,467

• Executive led initiative

• Executives from every campus were involved in project work

• Regional Referral Center (RRC) became a system entity

• Patient Flow Center functions are part of system strategic plan, presented to OHS Board, System Leadership meetings, CNO councils, etc…

• Patient flow stats reported out in Daily Connection

• Everything is now transparent:

• PFC Daily Huddle – Transfers, Misses, Declines, etc…

• Automated Shift Reports - Staffed beds, bed blocks, holds, etc…

• Bed Assignment Decline Reports

Culture Change

“Change Ain’t Easy”

Tier 1Frontline

Department Huddle

Tier 2Division DON,

Director, AVP, VP Huddle

Tier 3Division/Region Executive Team

Huddle

Tier 4System Executive

Team Huddle

7am-8:25am/pm

8:30am-9:25am

9:30am-9:55am

10:00 am

In Real-Time: Tiered Huddle Escalation Report

Over-Time: Solutions Cascaded: Stoplight Reports, Leader Rounding Communications, Open Forums etc.

What Gets in The Way of Doing Our Best for Our

Patients Every Day?

Live System-Wide

PILOT (Physician In Lead Of Transfers)

Plan of Care

Discussion

Prioritization Levels

Resource Utilization

Communication Improvements

Leading To Decreased

Hand-Off Errors

Auto-Launch: Auto-acceptance with parallel processing of transfer and transport

I. Increased risk of adverse outcome if not transferred now (goal bed assignment 1 hour/arrival 3 hours)

II. Increased risk of adverse outcome if transfer not complete within 6 hours (goal 2/6)

III. Higher level of care requirement without time-sensitive issue

IV. Deemed appropriate for outpatient evaluation/follow-up

V. Transfer not indicated medically

Ochsner System Patient Flow Center PILOT

Acuity Level Designation


Risk Adjusted Mortality Index (RAMI) Of Transferred Patients

2017:0.91

2018:0.77

Pre:0.91

Post:0.67

Pre:0.57

Post:0.34

Pre:0.91

Post:0.81

Pre:0.67

Post:0.37


“The 2/6 Initiative”: Assigning Levels And Time Goals To Transfers

Goal

Bed assigned: 1 hrIn Facility: 3 hrs

Expected Mortality

Observed Mortality

RAMI

1.9% 6.1% 3.31

Expected Mortality

Observed Mortality

RAMI

17.5% 0% 0.00

Bed assigned: 2 hrsIn Facility: 6 hrs

2.5% 4.8% 1.88 1.1% 0% 0.00

Level

2

Level

1

Goal Not Met Goal Met

• Patient flow and transfer acceptance must be embedded in the culture of your organization

• Placing key stakeholders in the same room improves patient flow communications

• Avoid handoff errors through improved communications and thorough documentation

• Transferring patients for a higher level of care in a timely manner saves lives


Key Takeaways

transferring patients to a higher level of care · time matters. transferring patients in less than...

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