Use of TeleMedicine to Improve Clinical and Financial Outcomes

Transcription

1 Use of TeleMedicine to Improve Clinical and Financial Outcomes Michael Ries, MD, MBA, FCCM, FCCP, FACP Medical Director, Critical Care and eicu Advocate Health Care November 12, 2015

2 Use of TeleMedicine to Improve Clinical and Financial Outcomes Assess your needs and your goals plan your strategy Integrate Tele-Medicine into system-wide strategy Collect accurate data, analyze the data, and share the data to demonstrate successes, drive accountability, and identify opportunities for improvement Listen to your customers (patients and clinicians)

3 Objectives Tele-ICU is a tool to improve quality in the ICU and how it is used depends on the needs of your ICU(s) Tele-ICU is a facilitator of change management as much as an intervention. Identify potential cost savings that can result from successful application of the above tools. It is important to state the goals and define metrics to track whether your use of the tele-icu is delivering added quality Then step back and reassess how you can use tele-icu to further improve the quality of Critical Care at your ICU(s) 3

4 ICU-Telemedicine is care provided to critically ill patients by off-site clinicians using audio, video, and electronic links to leverage technical, informational, and clinical resources. 4

5 Advocate Critical Care 18 ICU s 12 hospitals Five Level 1 Trauma Centers > 6000 physicians > 100 Intensivists 301 Critical Care beds (not including our Outreach programs additional beds) Total = 401 beds emobile carts in the ED Critical Access Unit > 24,000 ICU Admissions in 2014 Ventilator days: 29,706 on 6,419 cases Total direct costs (entire hospital stay) of $367M or 31% Advocate s total direct costs for inpatients in 2014 Total direct costs for days while the patients were treated in the ICU (excluding ED and OR costs) were approximately $200M or 17% of direct costs for inpatients eintensivist and ern coverage 24/7/365 with board-certified critical care physicians Mortality Index (APACHE IV) for 2015= (in 2010 = 0.72) 5

6 IT Culture Strategy 6

7 Target State A patient-focused process enacting evidence-based best practices and standardized protocols provided by one unified critical care team with collaboration at the bedside, among sites, and with the eicu. 7

8 The Goal Improve The Quality of Care We Provide To Our Critical Care Patients and Reduce Costs 8

9 Benefits/ROI/VOI Clinical Reduced mortality LOS Reduce adverse events DVT Sepsis Mortality Ventilator days/vap s CLABSI s Reduce Transfusions Improve nutrition Increase mobility Financial Leapfrog compliant Reduced costs ( avoid harm, fewer complications, VAPs, ADE s, sepsis, cost of 24/7 onsite intensivists.) Reduced LOS Increased Capacity Reduce unnecessary tests, xrays Reduce transfers to higher level facility Other Standardize the delivery of ICU care (workflows and protocols) Leverage scarcity of board-certified intensivists Facilitate Data Reporting Process Flow Variability (Gap) Solutions Avoid sleep deprivation Housestaff training and satisfaction Nurse satisfaction and support of less experienced RN s Patient/family satisfaction Decrease burnout of clinicians Extend Intensivist and critical care nurse career (most experienced) 9

10 Variance in Practice of Tele-ICU Technology Types of ICU s Bedside intensivist staff model Bedside documentation/cpoe availability Remote center staffing patterns Qualifications of providers Hours of Operation Buy-in by bedside clinicians Adherence to best practices Use of quality and safety information Intensivist handover of their patients Community v. Tertiary Facility Teaching v. Non-teaching 10

11 What Does Tele-ICU do to Improve Quality? Disease Management - Acute interventions - Patient surveillance for proactive intervention Population Management Best Practices System Engineering Support Individual Unit Special Needs Process flow variability through gap analysis Education - Resident erounds - Nurse Mentoring 11

12 What Does Tele-ICU do to Improve Quality? Disease Management - Acute interventions - Patient surveillance for proactive intervention Population Management Best Practices System Engineering Support Individual Unit Special Needs Process flow variability through gap analysis Education - Resident erounds - Nurse Mentoring 12

13 What Acute Issues Does Tele-ICU Deal With? First look at all new admissions (seen within 30 minutes) Ventilator issues Arrhythmias, especially atrial fibrillation with rapid ventricular response Hypotension Electrolyte abnormalities X-ray checks requested by residents or nursing MD presence at code, RRT transfer, or before on-site MD arrival Adjustment of sedation Need for GI prophylaxis Ventilator liberation assistance Antibiotic stewardship Glucose management 13

14 Tele ICU Experience Interventions Clinically Significant Intervention Number Percentage Best Practice Adherence % Comprehensive Adm Review % Response to Instability 760 7% Alter Ventilator Settings 723 6% Intervention Prevent Instability 679 6% Alter dx/dx Plan 570 5% Antibiotic Sensitivity Change 556 5% Med Admin 203 2% Direct Life Saving % Lilly J In Care Med 2009

15 What Does Tele-ICU do to Improve Quality? Disease Management - Acute interventions - Patient surveillance for proactive intervention Population Management Best Practices System Engineering Support Individual Unit Special Needs Process flow variability through gap analysis Education - Resident erounds - Nurse Mentoring 15

16 Population Management VAPs prevention DVT prophylaxis CLABSI Prevention Sepsis screen Ventilator liberation Sedation Management CPR Auditing enutrition epharmacy Palliative Care CAUTI Prevention Ventilator Induced Lung Injury (VILI)

17 eicu Report Sheet 17

18 18 Ventilator Associated Pneumonia(VAP) Bundle Assessment Screen

19 Proportion Count Percent VAP Compliance CMC MICCU 4Q2011 1Q2012 2Q2012 3Q2012 4Q2012 1Q2013 2Q2013 3Q2013 4Q2013 All ICU Units Vent Days Compliant Vent Bundles % % % % % % % % % Non-Compliant Bundles Non-Compliant for Sedation Vacation Non-Compliant for Assess Extubation Readiness Non-Compliant for GI Bleed Prophylaxis Non-Compliant for DVT Prophylaxis Non-Compliant for HOB30 PM Non-Compliant for HOB30 AM CMC MICCU Vent Days Compliant Vent Bundles 70 96% 74 94% 65 98% 67 93% % % 57 90% % 23 96% Non-Compliant Bundles Non-Compliant for Sedation Vacation Non-Compliant for Assess Extubation Non-Compliant for GI Bleed Prophylaxis Non-Compliant for DVT Prophylaxis Non-Compliant for HOB30 PM Non-Compliant for HOB30 AM VAP compliance (25 months rolling) Components contributing to Non-Compliance in Ventilator Bundle (3 months) 1.0 _ UCL=1 P= LCL= No Non-Compliant items over the last 3 months Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 4Q 2010 Date 2Q Q Q2012 4Q Q Q Type Sedation Vacation Other Count 1 0 Percent Cum %

20 ICU VAP: Avoided Cost Trend 20 Bethany Hospital excluded from January 2007 forward BroMenn Medical Center included starting in 2010 Sherman Hospital included starting in 2013 Data represents Adult ICU units only

21 DVT Compliance CMC MICCU All ICU Units Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 DVT Days DVT Compliant % % % % % % % % % No prophlaxis Compliant via Contra-indication Type of Prophlaxis Mechanical % % % % % % % % % Pharmicalogical % % % % % % % % % Combined theropy % % % % % % % % % CMC MICCU DVT Days DVT Compliant % % % % % % % % % No prophlaxis Compliant via Contra-indication Type of Prophlaxis Mechanical % % % % % % % % % Pharmacological % % % % % % % % % Combined therapy 46 9% 64 13% 74 14% % 55 10% 55 10% 77 14% 53 11% 42 8% DVT Compliance (25 months rolling) Type of prophlaxis used UCL=1 _ P= LCL= % 90% 80% 70% % 50% 40% 30% 20% Combined therapy Pharmacological Mechanical 0.70 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 10% 0% Dec-09 Jan-10 Feb-10 Mar-10 All ICU Units current month 21

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24 Sepsis Hospital Mortality Index Target Index not benchmarked by Philips Data reflected is subject to rounding Data Source: APACHE IVa/ 3Q14, 4Q14, 1Q15, 2Q15 Target Index not benchmarked by Philips 2 4

25 What Does Tele-ICU do to Improve Quality? Disease Management - Acute interventions - Patient surveillance for proactive intervention Population Management Best Practices System Engineering Support Individual Unit Special Needs Process flow variability through gap analysis Education - Resident erounds - Nurse Mentoring 25

26 Systems Engineering Define system problems, stakeholders, and goals Prioritize development of a system to meet these goals Use predefined metrics to verify that the completed system is fulfilling stated goals 26

27 Final Target State Guiding Principles Improve Communication/Coordination Achieve System Standardization of Care but with site innovation Creating a Critical Care Team with a strong leader Documentation/Technology Integrate Services (e.g. Pharmacy, PT, Resp Therapy ) Enable the Clinical Staff to care for the patient 27

28 28 Connect the Process to the Outcomes

29 Ventilator Days (Actual/Predicted) System-wide ventilator days were at a ratio of 1.19 to the predicted ventilator days as of 3/31/2012. Achieving a ratio of 1.00 would reduce approx. 4,600 ventilator days. Under the assumption that the excess ventilator days are substituted for a med/surg day, the improvement opportunity saves $3.0 million on an annual basis. Projected savings assume half of opportunity can be achieved in year 1 and the full savings (ratio of 1.00) in year 2. 29

30 KRA Target Overview and Weights 67% Measure Min Target Max Weight ICU Ventilator Days Index Baseline Mid of Min/Max 90th 19.0% CLABSI (ICU) SIR 50th 75th 90th 9.5% CLABSI (non-icu) SIR 50th 75th 90th 9.5% Unassisted Fall Percentile Rank 50th 75th 90th 19.0% 33% Culture of Safety Survey Percentile 50th 75th 90th 10.0% LOS Moderate Mid of Min/Max Well 11.0% CI PHO Score TBD TBD TBD 11.0% Readmissions Rate 50th 63rd 75th 11.0% Lower weight on duplicative measures LOS and readmissions appear in both CI and AdvocateCare index 30

31 Actual/Predicted Mortality Ventilator Day Improvement Summary Health outcomes results: 1938 fewer vent days 3Q13 vs 4Q fewer ICU days 7.4 pts given Sedation Vacation and SBT saves one life Advocate = 828 lives saved Total cost savings: Represents $1.35M* *Savings assumes ICU vent day substituted with Med/Surg Day ICU Mortality APACHE Predicted

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34 ICU CLABSI: Avoided Cost Trend 34 Bethany Hospital excluded from January 2007 forward BroMenn Medical Center included starting in 2010 Sherman Hospital included starting in 2013 Data represents Adult ICU units only

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36 What Does Tele-ICU do to Improve Quality? Disease Management - Acute interventions - Patient surveillance for proactive intervention Population Management Best Practices System Engineering Support Individual Unit Special Needs Process flow variability through gap analysis Education - Resident erounds - Nurse Mentoring 36

37 Collaboration with Individual Sites on Certain Processes Pneumonia Screening CPR Audit Central Line insertion bundle compliance DVT Intensity of Prophylaxis Tele-Stroke Program Sedation Withdrawal Multidisciplinary Rounds ED Sepsis Management Resident Coverage/Nurse Mentoring enutrition ED Boarders 37

38 Grand Total ED Boarders 2014 Admit to ICU January 6698 February 3130 March April May June July August September October November December Grand Total

39 Patient Safety Story An elderly patient arrived to the ED with severe shortness of breath and O2 sats in the 70 s. She refused intubation and was placed on BiPap. The decision was made to admit the patient and an ICU bed was requested. The ED was informed there were no beds available. While the patient was boarding in the ED, she was not tolerating BiPap and was having runs of V- Tach. The ED physician intubated the patient. The intensivist discussed the case several times with the ED physician, but did not come down to see the patient. Four hours later, the patient was still waiting for an ICU bed. She had continued runs of V-Tach and was given Mag and Amiodarone.

40 Patient Safety Story The patient continued to receive care in the ED, including an EKG. Sixteen hours after the initial bed request, the patient was assigned a bed and report called to the MICCU. A repeat EKG identified a possible STEMI. Serial troponins identified STEMI. Three hours later the patient was taken to the Cath Lab and clinically progressed and was then considered a poor candidate for a CABG. The patient was returned to the ICU. Care was withdrawn and the patient expired.

41 Cause Map e Limited treatment options for cardiac condition Pt admitted to MICCU and holdingin ED No beds available Patients awaiting bed availability to transfer from MICCU. Lack of available beds due to census. Patient Safety Goal Impacted Death Cardiogenic shock Significant myocardial injury Delay in cardiac cath Delay in diagnosing STEMI ED physicians cannot write admit orders Credentials do not allow Patient hemodynamic unstable No admitting orders written on ICU holds in ED. No repeat labs/ekgs ordered No ICU protocols utilized in ED Patient not seen in ED by attending or MICCU docs/residents Intensivist/ Resident from MICCU not involved in patient care in ED MICCU residents work under intensivists who do not see patients before admit to MICCU Too busy with MICCU patients

42 Corrective Action Collaborate with eicu team to identify potential solutions o 4 eicu carts o Create workflow process o Hand off process with ED physician, ED resident, ED RN, Intensivist and eicu MD o First eicu service in an ED with a continuous workflow process

43 ICU patient is ED, ICU bed needed Physician places ICU bed request after Dr. Done ICU Admission Boarding in ED Workflow Patient is admitted as Inpatient status ecare Mobile Cart activated & ealert button pressed by ED RN ED staff enters MRN, Pt Name (Last, First) on monitor eicu Clinician video assesses patient upon notification Hand-over (Follow Communication Workflow) ED Physician or Resident puts in page to initiate 5-way sign-out ED notifies eicu of transfer to MICCU bed by ealert Bed request to Bed Board eicu receives text page from bed board ED notified by bed board that ICU bed not available MICCU bed not available if less than 2 open beds Desk clerk places patient into ICU Virtual Hold Bed ECC5, ECC6, ECC7, ECC8 ED staff notifies eicu of admission Contact info from faxed eicu Assignment Sheet for ED RN 1. Name 2. Patient ID (MRN) 3. Diagnosis 4. Attending Intensivist 5. ED room number 6. Virtual Unit Admit Date/Time eicu HCA admits patient into ecaremanager Verifies lab and trended vital signs Enters height, weight and other data per eicu process eicu Page initiated by resident Call in to Tie-Line for hand-over Intensivist ED Physician RN +/-Attending Resident RN

44 Downgrade, 6 ICU, 20 Downgrade, 8 ICU, 13 Downgrade, 7 ICU, 9 Downgrade, 22 Downgrade, 16 Downgrade, 23 Downgrade, 7 Downgrade, 3 ICU, 7 ICU, 27 ICU, 33 ICU, 31 ICU, 29 Downgrade, 5 Grand Total, 26 Grand Total, 21 Grand Total, 16 Grand Total, 10 ICU, 18 Grand Total, 49 Grand Total, 49 Grand Total, 54 Grand Total, 36 Grand Total, 23 Downgrade, 92 ICU, 169 Grand Total, 261 Monthly emobile Cart Count by Discharge to ICU vs Downgrade /2015 3/2015 4/2015 5/2015 6/2015 7/2015 8/2015 9/ /2015 FEB-OCT

45 Downgrade, 23% Downgrade, 19% Downgrade, 38% Downgrade, 33% Downgrade, 30% Downgrade, 22% Downgrade, 44% Downgrade, 45% Downgrade, 43% Downgrade, 35% ICU, 56% ICU, 55% ICU, 62% ICU, 57% ICU, 67% ICU, 65% ICU, 70% ICU, 77% ICU, 81% ICU, 78% Monthly emobile Cart Percent by Discharge to ICU vs Downgrade 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2/2015 3/2015 4/2015 5/2015 6/2015 7/2015 8/2015 9/ /2015 FEB-OCT

46 Comparison: 2014 ER to ICU LOS vs 2015 emobile LOS 2014 ER to ICU LOS 2015 emobile LOS Feb Mar Apr May Jun Jul Aug Total 2014 ER to ICU LOS emobile LOS

47 What Does Tele-ICU do to Improve Quality? Disease Management - Acute interventions - Patient surveillance for proactive intervention Population Management Best Practices System Engineering Support Individual Unit Special Needs Process flow variability through gap analysis Education - Resident erounds - Nurse Mentoring 47

48 eicu Associate Satisfaction Trends 100 Percentile Ranking Percentile Ranking Fall 2005 Spring Fall Spring Fall 2007 Spring 2008 Fall 2008 Spring Fall 2009 Spring 2010 Fall 2010 Spring 2011 Fall 2011 Spring 2012 Fall 2012 Spring 2013 Fall

49 Objectives Tele-ICU is a tool to improve quality in the ICU and how it is used depends on the needs of your ICU(s) Tele-ICU is a facilitator of change management as much as an intervention. Identify potential cost savings that can result from successful application of the above tools. It is important to state the goals and define metrics to track whether your use of the tele-icu is delivering added quality Then step back and reassess how you can use tele-icu to further improve the quality of Critical Care at your ICU(s) 49

50 Use of TeleMedicine to Improve Clinical and Financial Outcomes Assess your needs and your goals plan your strategy Integrate Tele-Medicine into system-wide strategy Collect accurate data, analyze the data, and share the data to demonstrate successes, drive accountability, and identify opportunities for improvement Listen to your customers (patients and clinicians)

51 Questions? Thank You! Contact: 51