Transforming Health Care Delivery through System Integration of the Resurrection eICU® Program

Transforming Health Care Delivery through System Integration of the Resurrection eICU ® Program Becky Rufo DNSc RN CCRN Resurrection eICU Program Operations Director Resurrection Health Care, Chicago Insert logo 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

Activated July 10, 2007 182 critical care beds monitored 14 ICUs, 7 Acute Care sites 1 LTACH Resurrection eICU ® COR eRN/DA : 24/7 coverage eMD : M-F from 4PM to 6:00AM Sat/Sun from 11AM-6:30PM © 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? © 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. © 2010 Resurrection Health Care

ICU LOS Reduction Compared 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. © 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%. © 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. © 2010 Resurrection Health Care

Transformational Strategies ROI Risk Reduction © 2010 Resurrection Health Care Technology Operational Clinical Financial Electronic documentation Wireless carts Multidisciplinary integrations Mortality/ LOS Standardization of: Protocols Best practice Policies/Guidelines Performance Measures/outcomes Workflow redesign

Integration Information Service New Care Delivery Model - Onsite and Remote Teams © 2010 Resurrection Health Care Respiratory Therapists & Dietitians Cardiac Rehab Residents & Attending Physicians Nurses & Student Nurses Physicians Pharmacy ICU Managers / Directors Marketing Medical Records Dept. / Coder Finance Department Risk / Claims / Legal Case Managers / Social Workers Executive Leadership Team Quality Department ICU

Fast Track to Integration and Performance Driving forces to Integration IS and Clinical Partnership APACHE/Benchmark Reports Evidence-Based Practice Clinical Resource Standardization Clinical Risk Reduction Multidisciplinary Collaboration 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 © 2010 Resurrection Health Care

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 © 2010 Resurrection Health Care

Impact of Integration Clinical skills Critical Thinking Efficiency Energized Positive Empowered © 2010 Resurrection Health Care Patient Safety/Quality Retention Clinical Risk Reduction Standardization Best Practice Documentation

© 2010 Resurrection Health Care Consistent system ICUs mortality/LOS ratios< 1.0 0.52 reduction in ICU mortality. LTACH 8 Bed ICU (first 4 months). (*) ICU metric $1250/day saved in labor & supply costs. Non-ICU metric $300/day saved in labor & supply costs. $72 K additional revenue $387 K 50% LOS reduction. 3% reduction in unplanned discharges. Highest RHC APACHE scores (73-78). 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

Best Practice Compliance: Q2 2009 © 2010 Resurrection Health Care Measure Metric Target Q109 Q209 Q309 Q409 All e ICU 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 Use Compliance for at risk surgical & ACS patients >80% 60-80% <60% Glycemic Control Average daily glucose < 150 mg/dL > 80% 60-80% < 60% Complications Incidence 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

eICU ® -ICU ICU turnover Reviewed quarterly Quality: APACHE Report RHC Quality Scorecard Data Balanced 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 “ 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

Skilled Communication The virtual ICU identifies communication and information barriers went unnoticed Lack of consistent and efficient communication #1 contributor to errors/ increased risk AACN Standards for Establishing and Sustaining Health Work Environments © 2010 Resurrection Health Care Technology constraints Paper EMR Funding Fragmentation Poor Organizational Direction Lack of Vision Poor Partnerships “ Gaps”

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 © 2010 Resurrection Health Care

Clinical Risk Reduction Pneumothorax Perforated VISICU Suicide Falls IV maintenance Phlebotomy Feeding Tube placement Substance Abuse Examples of Risk Reduction Quality Safety $$$$ © 2010 Resurrection Health Care VS monitoring Medication administration Respiratory failure Quality Safety $$$$$

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% © 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 donation 70,000 people awaiting kidney transplant 28,000 people are transplant recipients < 2% of hospital deaths are medically eligible Responding to the need © 2010 Resurrection Health Care

Virtual ICU MD collaborates with onsite team to provide emergent interventions required to preserve organ function. 84 year old donor gave life to young child June 2008 – present: Dramatic improvement in referrals (100% referrals at level 2 Trauma center) The difference of one call…. © 2010 Resurrection Health Care

Nursing Empowerment © 2010 Resurrection Health Care eICU Nurse Role definition Scope of practice Critical synthesis Leadership Role Model/Mentor ICU Nurse Resources Partnership Critical thinking Availability of data Nursing Students Clinical Rotation Role model Leadership Nursing Leadership Accountability IS/Clinical partnership

AONE Guiding Principles for Future Care Delivery The 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 Kit Informatics standardization, resource TIGER Initiative (Technology Informatics Guiding Education Reform), 2006 Transform nursing education, practice into an automated information driven environment. © 2010 Resurrection Health Care

Institute of Medicine (IOM) Statements on Quality Patient Safety And Quality Information systems, Data standards, National infrastructure are key to improving Patient safety © 2010 Resurrection Health Care To Err is Human (2000) Crossing the Quality Chasm (2001) Patient Safety, Achieving A New Standard of Care (2003)

IOM Recommendations Patient 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 Programs Develop patient safety programs to encompass case findings, analysis and system redesign IOM Recommendations © 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

Transforming Health Care Delivery through System Integration of the Resurrection eICU® Program

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Transforming Health Care Delivery through System Integration of the Resurrection eICU® Program

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