A strategic integration of projects to improve patient flow by improving quality of care Bela Patel MD Associate Professor of Medicine UT Health Science Center Houston Memorial Hermann Hospital Texas Medical Center ID: 706287
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Evolution of CS&E Program ImpactA strategic integration of projects to improve patient flow by improving quality of care
Bela Patel MD
Associate Professor of Medicine
UT Health Science Center Houston
Memorial Hermann Hospital – Texas Medical CenterSlide2
UT Health Science Center Houston &Memorial Hermann HospitalKhalid Almoosa MDLillian Kao MDPratik
Doshi
MD
Brandy
McKelvy
MD
Ruth
Siska
RN, Tammy Campos RN
Kathy Luther RN, Kathy Masters
Jeffrey Katz MD, Eric Thomas MD
Divisions of Critical Care, Pulmonary and Sleep Medicine
MHH nurses, respiratory therapy, pharmacySlide3
Memorial Hermann HospitalTexas Medical Center1050 Bed Level 1 Trauma Center65,000 Emergency Department visits per year
▪ 37% admitted to hospital
▪ 10% ICU Admissions plus Transfers
150 ICU Beds
16 MICU Beds
1200 admissions/year> 95% capacity Slide4
MICUSlide5Slide6
ICU Safety and Hospital FlowSlide7
AIM STATEMENTDecrease MICU length of stay by 25% through reduction in complication rates and improvement in compliance with evidenced based practices over 36 months to improve flow and capacity. Slide8
Process MapSlide9
Outcomes Measures: Decreased Length of StaySlide10
Outcome Measures:Reduction of MortalitySlide11
Outcome Measures: Reduction of Complications (Codes, Infections)Slide12
Outcome Measures:Implementation of Sepsis BundlesSlide13
Outcome Measures:Compliance Ventilator WeaningSlide14
Outcome Measures:Improved CommunicationSlide15
Measured Outcomes:Reduced ED to ICU timeSlide16
Measured Outcomes:Reduction of CostsSlide17Slide18
Delayed ICU transfer (>4 hours from care complete to ICU arrival)
▪ Increased hospital mortality
▪ Increased hospital LOS
▪ Increased ICU LOS
Chalfin et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit care med 2007; 35: 1477-83.
Admission Delays to the ICUSlide19
Baseline Data March 08- February 09Pratik Doshi MD
<4 hours
>4 hours
Patients
345
314
% of total patients
52%
48%
Mortalty
Rate
14%
17%
Hospital LOS
9.10
10.30
CMI
2.33
2.60
Age
55
58
% Male
52%
48%
% Female
48%
52%
30 day readmits
40
32
30 day readmits-- Same DRG
12
7
Care Complete to Depart MICU Admits
Mortality
18% higher
Length of stay
11% higherSlide20
Decreasing Admission DelaysSpin FasterSlide21
Reducing EC – ICU transfer timesSlide22
Reduced LOS by Reducing Admission DelaysSlide23Slide24
Reduced Codes by 24%Slide25
GeneralizabilityRRT protocols and structure have spread to 9 hospitals in the system Slide26Slide27
Sepsis Resuscitation BundleSerum lactate measuredBlood
cultures prior
to antibiotic administration
Broad-spectrum antibiotics
administered
Within 3 hours of ED arrival or 1 hour non-ED admission
Treat hypotension with fluids +/-
vasopressors
I
nitial
minimum of 20
mL
/kg of crystalloid
Vasopressors
to keep MAP
>
65 mm Hg
Persistent hypotension
Maintain
central venous pressure
> 8 mm Hg
Central venous
O
2
saturation (Scvo2) > 70%Slide28
Hyperglycemia protocolSlide29Slide30Slide31
Mortality RatesSlide32
Length of StaySlide33
Sepsis Management SpreadSlide34Slide35
Increasing Compliance Ventilator WeaningBrandy McKelvy MDSlide36
Reduction in Ventilator DaysSlide37
Reduction in LOSSlide38
Generalizabilty Expansion into multiple ICUs next month followed by global implementation for the 11 hospital systemSlide39Slide40Slide41
Beyond the BundlesSlide42
VAPs to Zero for 40 monthsSlide43
GeneralizabilityTSICU Zero VAPS for 28 monthsCCU Zero VAPS for 18 months72% Reduction of VAPS across 7 ICUsExpanded Bundle Elements to 12 hospitalsSlide44
Zero Central Line Infections 12 Months Slide45Slide46
Generalizability6 ICUs7 Hospitals76% Reduction in Central Line InfectionsSlide47
Impact
Infection
Increased LOS
Added cost
Pneumonia
6
$57,000
Bacteremia
7
$63,000
Wound
7
$3,100
UTI
1
$700Slide48Slide49
Old Process MapKhalid Almoosa MD
5 – 7 days
Patient admitted to the MICU
Treatment
Family conference
High risk of death
Palliative care
Ethics
Delays in family conferences
No structure to conferences
No process for organizing conferences
Inconsistency among MDs
No timeline “1 more day”
Not multidisciplinary; no attending
Delays in palliative careSlide50
New Process MapHigh risk-of-death patients identified
Schedule family conference
Patient admitted to the MICU
Team members notified
Family conference
Decisions
Documentation
Future meetings
24 hours
Nurse manager
Nurse manager or Social workerSlide51
Baseline 10.1 daysSlide52
Improved CommunicationDecreased LOSSlide53
Results: Length of Stay Decreased by 28.5%Slide54
Results: Increased Admissions to MICU by 9.4% Slide55
Results: Increased Capacity by 9.5% Slide56
Reduced Mortality by 13%: Slide57
CMISlide58
ROI Through improved quality of care and safe practices, these changes collectively resulted in an overall savings of $5.1 million per year in decreased length of stayAdditional revenue from increased admissionsSlide59Slide60Slide61
ICU Utilization Tool: 31 days Slide62
Next Steps for Quality Improvement?Slide63
Thank you