transforming health care delivery through system integration of the resurrection eicu® program
DESCRIPTION
How Resurrection Health Care implemented a 24/7 specialized care system via centralized remote patient monitoring by intensivists that has reduced medical errors and ICU mortality, improved patient outcomes, saved costs plus enabled tracking of patient vital trends.TRANSCRIPT
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Transforming Health Care Delivery through System Integration of the Resurrection eICU® Program
Becky Rufo DNSc RN CCRNResurrection eICU Program Operations DirectorResurrection Health Care, Chicago
I DO NOT have any significant financial relationships that create, or may be perceived as creating, a conflict related to this educational activity.eICU® is a registered trademark of Phillips-VISICU
© 2010 Resurrection Health Care
• The clinical impact on risk reduction, patient safety and quality.
•The operational and financial benefits of a virtual ICU.
• Innovative utilization of the virtual ICU to enhance performance outcomes
Program Objectives
© 2010 Resurrection Health Care
The virtual ICU provides an organizational and technology platform to transform critical care by redesigning the way critical care is structured and managed.
Optimizing core clinical operations using information technology to drive significant quality and financial improvements
Clinical Transformation
© 2010 Resurrection Health Care
Resurrection eICU® COR
Activated July 10, 2007• 182 critical care beds monitored• 14 ICUs, 7 Acute Care sites 1
LTACH
eRN/DA: 24/7 coverage
eMD: M-F
from 4PM to 6:00AM
Sat/Sun
from 11AM-6:30PM
© 2010 Resurrection Health Care
© 2010 Resurrection Health Care
More eyes, ears, enhanced care
© 2010 Resurrection Health Care
• Patient safety and quality
• Leverage of technology to accelerate critical care delivery using an onsite/remote model
• Incorporates telemedicine communications, clinical information systems, decision-support tools.
• Incorporates best practice, standardization, clinical resource and workflow redesign
• Consistent reporting mechanism
Virtual ICU?Virtual ICU?
© 2010 Resurrection Health Care
© 2010 Resurrection Health Care
Hospital Mortality for ICU Patients
Based on data collected from three ICUs pre and post eICU Program implementation, there was an overall 43% reduction in risk adjusted hospital deaths of ICU patients compared to the baseline period.
Q3 2008
All
Hospital Deaths
Hospital Deaths
Hospital Deaths
Hospital Deaths
Hospital Deaths
If at Pre Risk Adjusted Rate 443 97 124 112 109
Actual 254 60 78 62 54Savings 188 37 46 50 55
Percentage Reduction 43% 38% 37% 45% 50%
4 Quarter Total Q4 2007 Q1 2008 Q2 2008
© 2010 Resurrection Health Care
Hospital Standardized Mortality Ratio
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Pre Q4 2007 Q1 2008 Q2 2008 Q3 2008
Act
ual
:Pre
dic
ted
All Units
© 2010 Resurrection Health Care
ICU LOS ReductionCompared to baseline, the three ICUs had a combined reduction of 42% in risk adjusted ICU Days. This was a net savings of 6,171 ICU days over the 12 months.
Q3 2008
All ICU Days ICU Days ICU Days ICU Days ICU Days
If at Pre Risk Adjusted Rate 14,714 3,110 4,142 3,903 3,559
Actual 8,543 1,575 2,543 2,200 2,226Savings 6,171 1,535 1,599 1,704 1,333
Percentage Reduction 42% 49% 39% 44% 37%
Average Patient Days' Reduction 2.2 2.7 2.0 2.2 1.9
4 Quarter Total Q4 2007 Q1 2008 Q2 2008
© 2010 Resurrection Health Care
ICU LOS Ratios
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Pre Q4 2007 Q1 2008 Q2 2008 Q3 2008
Act
ual
:Pre
dic
ted
All Units
© 2010 Resurrection Health Care
Hospital Mortality Extrapolation to Resurrection Health System
Over the course of the 12 months there were almost 500 fewer in-hospital deaths of ICU patients than predicted – a reduction of 39%.
Q3 2008
All
Hospital Deaths
Hospital Deaths
Hospital Deaths
Hospital Deaths
Hospital Deaths
If at Pre Risk Adjusted Rate 1,216 168 240 338 469
Actual 737 108 166 197 266Savings 479 60 75 140 204
Percentage Reduction 39% 36% 31% 42% 43%
4 Quarter Total Q4 2007 Q1 2008 Q2 2008
© 2010 Resurrection Health Care
General Care Extrapolation to the Health System
Finally, there were 7,200 general care days fewer than predicted over the 12 months across the health system – a 17% reduction.
Q3 2008
All
General Care Days
General Care Days
General Care Days
General Care Days
General Care Days
If at Pre Risk Adjusted Rate 43,586 5,819 8,729 12,274 16,763
Actual 36,358 4,655 7,769 10,188 13,746Savings 7,228 1,164 960 2,087 3,017
Percentage Reduction 17% 20% 11% 17% 18%
Average Patient Days' Reduction 0.9 1.1 0.6 0.9 1.0
4 Quarter Total Q4 2007 Q1 2008 Q2 2008
© 2010 Resurrection Health Care
Transformational Strategies
Technology Operational
Clinical
FinancialElectronic documentation
Wireless carts
Multidisciplinary integrations
Mortality/ LOS
Standardization of:•Protocols•Best practice•Policies/Guidelines
Performance Measures/outcomesWorkflow redesign
ROI
Risk Reduction
© 2010 Resurrection Health Care
Information ServiceInformation Service
Respiratory Therapists & Respiratory Therapists & DietitiansDietitians
Cardiac RehabCardiac Rehab
Residents & Attending Residents & Attending PhysiciansPhysicians
Nurses & Student NursesNurses & Student Nurses
PhysiciansPhysicians
PharmacyPharmacy
ICU Managers / ICU Managers / DirectorsDirectors
MarketingMarketing
Medical Records Medical Records Dept. / CoderDept. / Coder
Finance DepartmentFinance Department
Risk / Claims / LegalRisk / Claims / Legal
Case Managers / Social Case Managers / Social WorkersWorkers
Executive Leadership TeamExecutive Leadership Team
Quality DepartmentQuality Department
ICUICU
Integration
New Care Delivery Model - Onsite and Remote Teams
© 2010 Resurrection Health Care
Driving Driving forces to forces to
IntegrationIntegration
Driving Driving forces to forces to
IntegrationIntegration IS and Clinical Partnership
APACHE/Benchmark Reports
Evidence-Based Practice
Clinical Resource
Standardization
Clinical Risk Reduction
Multidisciplinary Collaboration
Fast Track to Integration and Performance
Balanced Scorecard
National Recognition
Organizational and Executive Leadership Direction
Integration Model
Leveraging Innovation
© 2010 Resurrection Health Care
Why integrate an LTACH?
• Organizational direction to standardize ICU care across the health system
• Reduce ICU LOS• Integrate best practice
initiatives• Develop “ICU” concept• Improve utilization of
ICU beds• Prevent transfers from
LTACH to acute care
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Challenges in Implementing LTACH units
• Conceptual change to ICU• Technology use• Transition to electronic documentation• Standards in care• Best practice• Performance outcomes• Incorporate with Critical Care services
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Impact of Integration
Patient Safety/Quality
RetentionClinical Risk Reduction
StandardizationBest PracticeDocumentation
Clinical skills Critical ThinkingEfficiency
EnergizedPositive
Empowered
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Demonstrated Savings
• Reduced ICU LOS by 50%• Reduction in ICU and Hospital mortality• Hospital LOS reduced by 9.03 days • Substantial financial savings
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2007-2009 Data
ICU Days Saved 9,241 $ 11.5 M *
Non-ICU Days Saved 18,517 $ 5.60 M *
Lives Saved 1090
Unit Stays 20,175
APACHE Scores 57.4 - 59.5
Consistent system ICUs mortality/LOS ratios< 1.0
(*) ICU metric $1250/day saved in labor & supply costs. Non-ICU metric $300/day saved in labor & supply costs.
LTACH 8 Bed ICU (first 4 months).
50% LOS reduction. $387 K
3% reduction in unplanned discharges. $72 K additional revenue
0.52 reduction in ICU mortality.
Highest RHC APACHE scores (73-78).
© 2010 Resurrection Health Care
2008 and 2009 PhilipsVISICU eICU®
Impact Award recipient
© 2010 Resurrection Health Care
Best Practice Compliance: Q2 2009
Measure Metric Target Q109 Q209 Q309 Q409 All eICU Program Average: Q109
VTE Prophylaxis Compliance for At Risk patients
> 90%
80-90%
< 80%
Stress Ulcer Prophylaxis Compliance for At Risk patients
> 90%
80-90%
< 80%
Low Tidal Volume Ventilation
Compliance for ALI/ARDS patients
> 75%
50-75%
< 50%
Blood Transfusion Threshold
Transfused PRBCs (hemoglobin < 7gm/dL)
> 50%
20-50%
< 20%
Beta Blocker UseCompliance for at risk surgical &
ACS patients
>80%
60-80%
<60%
Glycemic Control Average daily glucose < 150
mg/dL
> 80%
60-80%
< 60%
ComplicationsIncidence of Acute Renal Injury /
patient stay
< 1.3%
1.3-1.6%
> 1.6%
Ventilator Days Median ventilator days
< 1.5
1.5-2.0
> 2.0
© 2010 Resurrection Health Care
eICUeICU®®-ICU-ICUeICUeICU®®-ICU-ICUICU turnover
Reviewed quarterly
Quality: APACHE Report
RHC Quality Scorecard Data
Balanced ScorecardBalanced Scorecard
Monitors system wide trends
Drives clinical best practice
Vision and organizational direction
Quality :Benchmark Reports
eICU® MD Interventions
© 2010 Resurrection Health Care
Learning in the trenches Learning in the trenches
“Mistakes made on a small scale can be overcome. Mistakes made when you’re at the top cost the organization greatly and damage a leader’s credibility”.
“The difference between average people and achieving people is their perception of and response to failure”
J.C. Maxwell (2008). Go for Gold
“Mistakes made on a small scale can be overcome. Mistakes made when you’re at the top cost the organization greatly and damage a leader’s credibility”.
“The difference between average people and achieving people is their perception of and response to failure”
J.C. Maxwell (2008). Go for Gold
© 2010 Resurrection Health Care
27© 2010 Resurrection Health Care
Longitudinal Mortality
28*APACHE IV predictions begin
© 2010 Resurrection Health Care
Longitudinal Length of Stay
29
* APACHE IV predictions begin
© 2010 Resurrection Health Care
•EngagementVision
Leadership
Communication
Direction•Outcomes
Commitment
•VisibilityVulnerability
Value
© 2010 Resurrection Health Care
Skilled Communication• The virtual ICU identifies
communication and information barriers went unnoticed
• Lack of consistent and efficient communication #1 contributor to errors/ increased risk
Technology constraints
Paper
EMR
Funding
Fragmentation
Poor OrganizationalDirection
Lack of Vision
Poor Partnerships“Gaps”
AACN Standards for Establishing and Sustaining Health Work Environments
© 2010 Resurrection Health Care
Lessons Learned
• Establish your power base• Know the application• Know the organization• Know current performance
metrics• Know financial operations• Executive sponsor/leadership• Integrate organizational model• Establish ownership
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National Safety Imperative
- IHI- JCAHO National Patient Safety Goals- CMS 2008 Complication Proposal- Health Care Reform, “Stimulus Proposal”- HIMSS- ATA - ACCP
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Clinical Risk Reduction
VS monitoring
Medication administration
Respiratory failure
QualitySafety$$$$$
Examples of Risk
Reduction
Pneumothorax
Perforated VISICU
Suicide
Falls
IV maintenance
Phlebotomy
Feeding Tube placement
Substance Abuse
QualitySafety$$$$
© 2010 Resurrection Health Care
Clinical Risk Reduction
• Partnership with Risk/Claims Management, Legal • Efforts to promote patient safety and quality• Medication errors• Standards of Care• Consistent communication of information• Procedure related• Complications• Equipment related
© 2010 Resurrection Health Care
Blood Transfusion Utilization (Hemoglobin >9-11 and > 11)
Goal: Reduction in blood administration for Hgb >9
Q4 2007: (3 sites): 29%
Q1 2008: (4 sites): 21%
Q2 2008: (6 sites): 17%
Q3 2008: (7 sites): 15%
Q4 2008: (8 sites): 17%
Q1-2 2009: 14%
0%
5%
10%
15%
20%
25%
30%
1
Q4 2007: (3 sites): 29%
Q1 2008: (4 sites): 21%
Q2 2008: (6 sites): 17%
Q3 2008: (7 sites): 15%
Q4 2008: (8 sites): 17%
Q1-2 2009: 14%
© 2010 Resurrection Health Care
eICU® Nursing Interventions(Jan-July 2009, n=1653)
• 46% (SBP <80mmHg)• 20% Respiratory/Oxygenation• 13% Lab values & follow up• Best practice• Patient Safety
– Side rails down
– Device, tubing, IV, lead disconnect, equipment
– Medication variance
© 2010 Resurrection Health Care
eICU® MD Interventions• # 1 Respiratory failure/airway
management• Hemodynamic (BP, HR)• Fluid / Electrolyte Imbalances• Sepsis/shock• Code management • Best Practice• Acute Renal Failure
© 2010 Resurrection Health Care
Routine Rounds Can Reveal Extraordinary Occurrences
Scenario 1
• In discussion with the patient, the patient reveals to the eICU nurse that he has had right arm pain since he had his blood drawn earlier in the morning.
• The eICU nurse was able to direct the
patient to lift up the sleeve of his gown. The eICU nurse is able to focus the camera in more closely on the patients arm to reveal a tourniquet in place from an earlier blood draw.
• The eICU nurse had the ability to collaborate with the primary care nurse by calling on the phone and describing the patient findings.
• While remaining focused on the patient, the
eICU nurse was able to witness the primary nurse removing the tourniquet from the patients arm.
Scenario 2
• Upon entering a patients room, the eICU nurse noticed the patient frequently wiping her nose.
• The eICU nurse asked the patient if she could offer her something for a ‘runny nose’. The patient denied a need for anything.
• As the eICU nurse continued her virtual rounds on the patient, she realized the patient was not wiping her nose with the tissue but in fact sniffing something from the tissue.
• The eICU nurse remained on camera with the patient but turned the volume off as she called the nursing unit on the phone and notified the primary care nurse on site of her findings.
• It was discovered that the patient was sniffing “HEROIN” which was leading to her exacerbation of asthma and elevated heart rate.
© 2010 Resurrection Health Care
Sometimes The Obvious is Overlooked
Scenario 1
• Sentry alerts revealed low pulse ox. readings on a patient
• The eICU nurse entered the room per camera and noticed a nurse at the bedside replacing the pulse ox. to the patient’s finger. A doctor was also listening to breath sounds as the patient visually displayed an increase in respiratory rate and difficulty breathing.
• The eICU nurse suggested an attempt to bag the patient and check ETT placement. However the primary nurse and physician ordered ABG’s and a portable CXR which would warrant a delay in obtaining results.
• In the meantime the patient heart rate started to brady down and the blood pressure was also unstable.
• The eICU nurse again suggested checking the ETT as she was calling a ‘Code Blue’.
• The primary nurse and doctor checked the ETT and noticed it was dislodged and in the patients mouth. Quick re-intubation led to prevention of loss of heart rate or blood pressure preventing a code situation.
Scenario 2
• Sentry alerts revealed a low blood pressure reading on a patient.
• The eICU nurse entered the room per camera to see the primary nurse administering a fluid bolus to the patient without improved BP results.
• While the primary nurse was beginning to administer pressors for BP support the eICU nurse was performing his patient rounds which included visualizing IV medicated drips.
• The eICU nurse noted the intubated patient to be on Propofol for sedation. The Propofol was at an unusually high rate. The eICU nurse and the primary nurse discussed the plan of care regarding BP control of the patient. After the primary nurse also recognized the Propofol rate to be unusually high, she decreased the rate, while maintaining sedation and
© 2010 Resurrection Health Care
Something to think about?
• Optimize clinical performance? • Redesign workflow processes?• Redundant documentation?• More effective daily rounding? • Communication breakdowns?• Increased clinical errors, “never events”• Educational needs?• Tracking outcome performance? Reporting
methods• Auditing staff performance?• Impact on budget? • Technology upgrades?• Regulatory requirements?
© 2010 Resurrection Health Care
100,000 people awaiting organ donation100,000 people awaiting organ donation– 70,000 people awaiting kidney transplant70,000 people awaiting kidney transplant– 28,000 people are transplant recipients28,000 people are transplant recipients– < 2% of hospital deaths are medically < 2% of hospital deaths are medically
eligibleeligible
Responding to the needResponding to the need
© 2010 Resurrection Health Care
• Virtual ICU MD collaborates with onsite team Virtual ICU MD collaborates with onsite team to provide emergent interventions required to to provide emergent interventions required to preserve organ function.preserve organ function.
• 84 year old donor gave life to young child84 year old donor gave life to young child
• June 2008 – present: Dramatic improvement June 2008 – present: Dramatic improvement in referrals (100% referrals at level 2 Trauma in referrals (100% referrals at level 2 Trauma center)center)
The difference of one call….The difference of one call….
© 2010 Resurrection Health Care
Resurrection System Key Metrics
24%34% 40%
61%81% 79%
90% 93%
2006 2007 2008 YTD 2009
Conversion Rate Timely Referral Rate
© 2010 Resurrection Health Care
© 2010 Resurrection Health Care
Nursing Empowerment
eICU NurseRole definition
Scope of practiceCritical synthesis
LeadershipRole Model/Mentor
ICU NurseResourcesPartnership
Critical thinkingAvailability of data
Nursing StudentsClinical Rotation
Role modelLeadership
Nursing LeadershipAccountability
IS/Clinical partnership
© 2010 Resurrection Health Care
AONE Guiding Principles for Future Care DeliveryThe Virtual and Presence Relationship of Care
• As technology advancements reframe the definition of presence, the patient remains at the center of care”.
• “Nurses of the future will value both virtual and presence-based caring”.
• “New & experienced nurses must be able to respond while working in virtual environments”.
• Technology Task Force Tool KitInformatics standardization, resource
• TIGER Initiative (Technology Informatics Guiding Education Reform), 2006Transform nursing education, practice into an automated information driven environment.
© 2010 Resurrection Health Care
Institute of Medicine (IOM) Statements on Quality
To Err is Human(2000)
Crossing the Quality Chasm
(2001)
Patient Safety, Achieving A New Standard of Care
(2003)
Patient Safety And
Quality Information systems,
Data standards,National infrastructure
are key to improvingPatient safety
© 2010 Resurrection Health Care
IOM RecommendationsPatient Safety Data SystemsPatient Safety Data Systems• Capture patient safety information as a by-
product of care, provide immediate access to patient information and decision support tools.
Comprehensive Patient Safety ProgramsComprehensive Patient Safety Programs• Develop patient safety programs to
encompass case findings, analysis and system redesign
IOM Recommendations
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So…What’s it like to the Operations Director?
© 2010 Resurrection Health Care
© 2010 Resurrection Health Care
Keys to Success • Seek role model/mentor• Power is knowledge• Know subject matter• Scripting• Conceptual/theoretical approach • Practice • Reflection• People of influence
© 2010 Resurrection Health Care
RHC eICU® Program2008 and 2009
IMPACT award recipient
NextGenWeb.org
© 2010 Resurrection Health Care
© 2010 Resurrection Health Care
Growth • Outreach• ED Integration• Tele-Neuro /Stroke• Tele-Health• Orientation/Mentoring
© 2010 Resurrection Health Care
“The names of the patients whose lives we save can never be know. Our contribution will be what did not
happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and
wedding they would have missed, and that grandchildren will know grandparents they might never
have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have
been.” ~Donald M. Berwick, M.D.
© 2010 Resurrection Health Care
“The names of the patients whose lives we save can never be know. Our contribution will be what did not
happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and
wedding they would have missed, and that grandchildren will know grandparents they might never
have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have
been.” ~Donald M. Berwick, M.D.
© 2010 Resurrection Health Care
© 2010 Resurrection Health Care
Feel free to contact me:
Rebecca Rufo DNSc RN CCRNResurrection eICU Operations DirectorResurrection Health [email protected]