Patients with Rib Fractures How We Decreased Unplanned Transfers to the ICU. Lillian Aguirre, DNP, CNS, CCRN, CCNS Orlando Regional Medical Center

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1 Patients with Rib Fractures How We Decreased Unplanned Transfers to the ICU Lillian Aguirre, DNP, CNS, CCRN, CCNS Orlando Regional Medical Center

2 Disclosures I do not have any disclosures

3 Background Struggling with ED ICU time non-intubated alerted patients

4 2016 PIPS Focus on Thoracic Trauma Improvement Strategies Patients 65y/o with 3 rib fractures Admit to ICU Trauma Critical Care CNS closely monitored those patients during their hospitalization Results Performance measure: Success rate for ALL patients with rib fractures that had an unplanned admission to ICU (Internal goal 97%)

5 Monthly PIPS Process & Reports Trauma Registry s Clinical Specialist Report based on discharge data Clinical Specialist sends report with outliers to the appropriate specialty s CNS Cases reviewed, opportunities identified, action plans developed Nursing units and Allied Health departments are informed of performance measures, opportunities for improvement, action plans and PI outcomes

6 Action Plan - Promote incentive spirometer (IS) use - Early ambulation - Documentation of IS volumes and actual activity level - During multidisciplinary rounds consider: I&Os Effectiveness of multimodal pain management Utilization & effectiveness of round the clock and prn opioid use Reported activity level Effectiveness of prescribed bowel regimen

7 Action Plan The Trauma/Critical Care Clinical Nurse Specialist: Continued to round on patients 65 y/o with 3 rib fractures along the continuum Thoroughly reviewed the cases of patient with rib fractures that had an any unplanned admissions to the ICU for remainder of the PIPS PI period Shared findings and performance reports with all stakeholders

8 Presenting the Plan at the GEMBA The action plan was posted & presented at GEMBA board sessions on stakeholder units or departments: ICU, Step-down, Med/Surg, Respiratory Therapy and In-patient Rehab Report graphs & improvement plan posted Action plan also presented at TQM meeting

9 Results Jan Oct 2017 Success Rates for Avoiding Unplanned Admission to ICU ALL Patients with Rib Fractures 100% 100% 100% 100% 100% 100% 94% 2 97% 1 Jan Feb Mar Apr May Jun Jul Aug Sep Oct 97% 1 92% 2 n=229 6 variances 98% avoided an unplanned ICU admission Success rate based on monthly performance = 97.37%

10 UNPLANNED ADMISSIONS TO ICU Patient Age # Ribs Fractured Initial Unit Case Summary Reason for ICU 1 <65 1 ICU Neuro & abdominal injuries exceeded rib fx Ventilator support in a Step-down unit (SDU) Abdominal cellulitis 2 >65 2 ICU Neuro injury exceeded rib fx injury Pulmonary 3 <65 6 ICU Pulmonary contusion. Long cardiac history. Ventilator support in a SDU 4 <65 2 ICU Head & spine injuries, TLSO brace + c-collar. Aggressive pulmonary therapies well documented 5 <65 4 (bil) ICU Bil rib fx 1-2, severe abdominal trauma RF Long ICU LOS. Ventilator support in a SDU 6 <65 7 (bil) ICU Hx COPD. Bil rib fx, L4 fx, in TLSO brace. ICU Gen floor SDU ICU SDU within 2 hrs SVT Pulmonary Required CRRT Pulmonary but transfer not necessary

11 Trauma Quality Improvement Program BENCHMARK REPORTS Unplanned Admissions to ICU ALL Trauma Patients Report Time Period Benchmark All Hospitals Spring 2017 Fall plus First 3 Quarters of plus First Quarter 2017 Orlando Regional Medical Center 1.9% 1.4% 2.2% 1.0%

12 Conclusion Emphasis on basic clinical management strategies was effective Unplanned ICU admissions of patients with rib fractures had more severe injuries or medical conditions complicating their ability to recover The strategies that were used to help improve clinical outcomes for this patient population were effective and contributed our improved TQIP benchmark score

13 ACS and Attendees Thank You! Also, a special acknowledgment to ORMC s Trauma PIPS Team Joseph Ibrahim, MD Trauma Program Medical Director Susan Ono, BSN, RN, PCCN-K Trauma Program Manager Nicole Rich, BSN, RN, CCRN Steven Soares, BSN, RN Trauma Program Registry Clinical Specialists