MUSC Critical Care Outreach Program Dee W. Ford, MD, MSCR Associate Professor of Medicine
Disclosures * Funding from the NIH, Department of Defense, and the National Palliative Care Research Center * No conflicts of interest
Integrating Research and Clinical Program Development * Overview * Identifying funding mechanisms * CREST * Developing a research team * Building on success * SE VIEW * SCTR Pilot Grant * Innovating research opportunity * Duke Endowment * Tele- medicine funding
My arduous funding saga * Completed pulmonary/critical care fellowship in 2005 * Completed MSCR in 2007 * Submitted 12 unfunded grants between 2005-2009 * Pilot proposals * Mentored proposals * Foundation sources * Federal sources
Grant Writing
Grant writing: Lessons learned * Science alone isn t sufficient But the science must be outstanding Career awards: right person, right mentor, right funder, and right institutional environment * Robust external review well in advance * Two- year time cycle * Develop a thick skin
Identifying funding mechanisms * ARRA and the NIH (2009) * $8.2 billion in extramural funding * NIH Challenge Grant program - $200M * 15 broad Challenge Areas * Multiple specific Challenge Topics * RO1 level proposal (RC1) * Plan for 200 projects, $1 million each * Why waste your time?
Identifying funding mechanisms Program Announcement: * 09- MD- 101* Creating Transformational Approaches to Address Rural Health Disparities. Research will focus on approaches, partnerships, and technologies for improving rural health outcomes. In addition, NCMHD is interested in proposals that utilize innovative outreach strategies that involve collaboration among traditional and non- traditional groups including new categories of community health workers, non- traditional occupations and settings.
Background * ICU beds account for >10% of hospital beds * represent 15-20% of all US healthcare expenditures * Overall mortality rate is 12-17% (hospital average 1.5%) * Dedicated intensivists improve ICU mortality and reduce costs HRSA Report, 2006, The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians.
Critical Care Workforce Shortage 7000 6000 FTEs 5000 4000 3000 2000 1000 0 Potential Shortfall 2000 2005 2010 2015 2020 Year Optimal Utilization Effective Supply HRSA Report, 2006, The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians.
Tele- Critical Care * Leverages limited professional resources to larger patient population via technology * Specialist directed care anywhere * Patient registry * Consortium to share data * Collaborative quality improvement
Technology Solutions - eicu
Tele- critical Care Tele- ICU command centers NEHI 2010, Critical Care, Critical Choices: The case for tele- ICU s in intensive care.
MUSC Telestroke Data June 30, 2013 * Over 3,500 consults * Over 600 patients treated with tpa * Over 880 transfers * Transfer rate from 12%- 59% * 12% transferred patients have NIR procedures * Patient profile * Average age 65 yrs, 44%< 65 yrs * 50% male * Average NIHSS 7
Available in the ED 24/7 Telemedicine cart
12 Active telestroke sites 18
Responding to funding mechanisms * Make your proposal congruent with the program announcement * In spirit and letter
Responding to funding mechanisms * Challenge grant program announcement specifics * approaches, partnerships, and technologies for improving rural health outcomes * Exploring telehealth and telemedicine science * Implementation of telehealth tools for improving rural health outcomes * Trans- disciplinary approaches to address rural health disparities through new and enhanced partnerships * New technological tools to train healthcare workers in rural areas to enhance health education, training and clinical care
Critical Care Excellence in Sepsis and Trauma: CREST * My first funded grant: ARRA and NIH * Over 20,000 applications received * 894 funded * Nothing ventured, nothing gained
CREST: Hypothesis and Aims * Hypothesis 1: A telemedicine program including education and clinical consultation between a tertiary care academic medical center and rural, local hospitals will significantly improve key treatment decisions and outcome measures in sepsis and trauma. * Primary Aim: Improve clinical, health systems, and provider outcomes related to the treatment of sepsis and trauma among patients at rural local hospitals. * Subaim 1a: Improve clinical evaluation, decision making, and outcomes for rural patients with sepsis and trauma receiving telemedicine consultations. * Subaim 1b: Evaluate the acceptance of a telemedicine program for sepsis and trauma among rural hospitals. * Subaim 1c: Assess the economic impact of a telemedicine system in treating patients with sepsis and trauma.
CREST: Hypothesis and Aims * Hypothesis 2: The patients treated by telemedicine in participating rural hospitals do not differ substantially from patients treated in participating hospitals prior to CREST. * Secondary Aim: Evaluate background (covariate) information about selection for telemedicine intervention and determine if telemedicine patients and hospitals are representative of care for this type of patient seen in rural hospitals. * Subaim 2a: Identify control patients with sepsis prior to the CREST intervention based on propensity score matching and compare them to the telemedicine group on key characteristics. * Subaim2b: Assess the effect of selected hospital characteristics (staff and structure), and patient characteristics (severity demographics, insurance), on the use of CREST technology and the association between these characteristics and the improvements in treatment and transfer decisions.
CREST: Approach * Build upon institutional/environmental strengths * Clinical * MUSC telestroke * Service lines (MACC, SACC) * Technical * PPN, light rail * Tele- stroke hub and spoke * Educational * AHEC * Institutional * Center for Health Disparities
CREST: Intervention * Combine clinical telemedicine program with an educational offering * Evaluate multiple aspects of the program
CREST: Evaluation plan * Process evaluation * Organizational readiness for CREST * Participation and utilization * Impact evaluation * Treatment decisions * Clinicians improve decision making * Outcome evaluation * Clinical * Systems/economic * Provider
CREST: Process evaluation A Mixed Methods Descriptive Investigation of Readiness to Change in Rural Hospitals Participating in a Tele- critical Care Intervention * Organizational model for readiness to change * Mixed methods BMC Health Services Research 2013; 13:33.
CREST: Health services research * Objective: Perform research that can be applied by physicians, nurses, health managers and administrators, who make decisions or deliver care in the health care system * Primary goals of health services research * High quality care * Reduce medical errors * Improve patient safety * Outcomes * Access * Cost * Patient outcomes
Developing a research team
Developing a research team * Health services research * Behavioral science * Biostatistics * Health economics
Building on success: SE VIEW * Southeastern Virtual Institute for Health Equity, Education, and Wellness (SE VIEW) * Department of defense * PI: Sabra Slaughter, PhD * 12 unique projects * Reducing rural health disparities in critical care
Building on success: SE VIEW * Observational stage * Acquired patient and hospital identified database from SC Office for Research Statistics * N ~ 80,000 cases * Evaluate volume- outcome relationships in two patient populations * sepsis * respiratory failure requiring mechanical ventilation
Building on success: SE VIEW A Sepsis Mortality Prediction Score for Use with Administrative Data * Utilize hospital discharge data including ICD- 9 codes and procedure codes to risk stratify patients with sepsis * Administrative APACHE score
Building on success: SE VIEW A Sepsis Mortality Prediction Score for Use with Administrative Data Calibration plot for sepsis mortality predication score 80 66 60 47 48 40 36 4.93 16 27.5 20 0 0 1 2 3 4 5 6 Decile Observed Deaths
Building on success: SE VIEW Proportion of Sample A Sepsis Mortality Prediction Score for Use with Administrative Data 70 60 50 40 30 20 10 0 0-20 21-40 41-60 >60 Risk Quintile Proportion of sample in risk quintile Proportion of quintile that died (p<0.0001) Proportion of quintile discharged home (p<0.0001)
Building on success: SE VIEW Hospital Case Volume is Associated with Mortality and Discharge Destination for Sepsis Admissions Association between Hospital Case Volume and Mortality and Discharge Destination. Variable Low Volume Intermediate Volume High Volume No. of hospitals 20 22 20 Mean sepsis cases/year (range) 43.51 (3-59) 221.67 (64-296) 706.92 (337-1153) Odds ratio (95% CI)* Mortality 1.46 (1.169-1.826) 0.792 (0.714-0.879) 1.0 Discharge to home 0.668 (0.544-0.819) 1.183 (1.089-1.284) 1.0
Building on success: SE VIEW A Sepsis Mortality Prediction Score for Use with Administrative Data
Building on success: SCTR Pilot Grant * 5% of all ICU patients are transferred * Single- center reports * Patients transferred to tertiary care center have worse outcomes compared to continuously at tertiary center * MUSC s Medical Intensive Care Unit receives > 800 patient transfers annually Iwashyna et al. Med Care 2009;47: 787 Combes et al. Crit Care Med 2005; 33:705- Rosenberg et al. Ann Intern Med 2003; 138:882-
Building on success: SCTR Pilot Grant Community Acute Care Hospital Emergency Department Long- term Care Facility
Building on success: SCTR Pilot Grant * Survey: Transitions in care among critically ill patients * Physicians, nurses, and administrators at top referring hospitals to MUSC s MICU * Literature review * Adapt existing measures * Develop new items * Key informant interviews..oops * Major revision!!! * Literature review * Adapt existing measures * Develop new items * Key informant interviews * Survey distribution
Innovating research opportunity * Emphasis on patient safety and quality improvement * Peter Pronovost Genius * Continuous quality improvement * Effective multi- disciplinary teams * MD, nursing, respiratory therapy, pharmacy, PT/OT, dietary, chaplaincy * Standardizing care * Protocols * Education, training, and experience * Telemedicine * Multidisciplinary rounds John and Catherine T. MacAuthor Award 2008 Kim et al. Arch Intern Med. 2010;170(4):369-376
Innovating research opportunity * Duke Endowment proposal: MUSC Critical Care Outreach Program 1. Multi-disciplinary education on VAP prevention E.g. MD (diagnosis, importance of early extubation), RT (clean/ replace equipment, daily spontaneous breathing trials), RN (elevate head of the bed, oral care) 2. Integration into MUSC Critical Care Quality E.g. Participate in joint quarterly infection control meetings, review VAP rates, discuss VAP cases and strategize ways VAP could have been prevented 3. Adapt MUSC s evidence based protocols to partner hospital care processes E.g. Review MUSC ventilator weaning protocol and adapt to partner hospital resources, review MUSC sedation protocol and integrate into partner hospital ICU
Innovating research opportunity Patient safety and quality improvement metrics for MUSC- CCOP Quality indicator National Benchmark, average score (worse- best score) a MUSC Hospital A Hospital B Fundamental patient safety and quality metrics ICU physician staffing 24.68 (5-100) a 100 5 5 Care of the ventilated 18.02 (0-20) a 18.33 Not reported 11.67 patient Ventilator associated pneumonia (VAP)* 2.1 1.3 TBD TBD Central line associated blood stream infection (CLABSI).54 (2.58-0) a.4005.56 1.6181 Innovative patient safety and quality initiatives Days on mechanical ventilation Not available 576/1000 patient days TBD TBD Sepsis identification and treatment Timely and appropriate Implemented TBD TBD Pain, agitation, delirium guidelines Early ICU mobility protocol antibiotics Use of standardized scales and treatment plan Physical therapist and proactive mobility protocol Implemented TBD TBD Implemented TBD TBD ICU patient satisfaction Not available 97 out of 100 TBD TBD ICU nurse satisfaction Not available 98 out of 100 TBD TBD
Innovating research opportunity Telemedicine to reach the rural August 13, 2013 Patients who need intensive medical care in rural parts of the state often must travel to Charleston for treatment. But a new partnership between the Medical University of South Carolina and a private health care technology company might eliminate those trips for some of the sickest people. A collaboration between MUSC and Advanced ICU Care will allow physicians to administer intensive care in rural South Carolina via telemedicine. The technology will help patients with life-threatening conditions in rural counties be seen by MUSC boardcertified critical care doctors, also called intensivists, without needing to be transported. Medical staff on site at the rural hospitals will be able to present the patient s condition to the Charleston doctor in live time via sophisticated video conferencing equipment. For a patient in critical condition this access can be the difference between life and death, said Dr. Pat Cawley, executive director of the Medical University Hospital. It also could save the state money. The General Assembly appropriated $12 million to MUSC so it could expand the reach of telemedicine to poorer, rural parts of South Carolina that have limited access to medical doctors and specialists.
Summary * Appropriate funding mechanisms * Multi- disciplinary research team * Synergistic research * Innovate research opportunity * Complex and costly interventions should include complex and well- supported evaluation plans
Acknowledgements Robert Adams, MD Alice Boylan, MD Samir Fakhry, MD Andy Goodwin, MD, MSCR Anbesaw Selassie, PhD Kit Simpson, DrPH Jane Zapka, ScD Laura Langston Katherine Taylor