Leapfrog Who, What, Why, Where,When Gary L. Weinstein M.D. Director of Pulmonary and Critical Care Presbyterian Hospital of Dallas

LeapfrogLeapfrogWho, What, Why, Who, What, Why,

Where,WhenWhere,WhenGary L. Weinstein M.D.Gary L. Weinstein M.D.

Director of Pulmonary and Director of Pulmonary and Critical CareCritical Care

Presbyterian Hospital of Presbyterian Hospital of DallasDallas

The Leapfrog Group: The Leapfrog Group: WhoWho

Founded by The Business Roundtable in Founded by The Business Roundtable in 20002000

Consortium of over 120 Fortune 500 Consortium of over 120 Fortune 500 companies and other large public and companies and other large public and private health care purchasersprivate health care purchasers

Provide health benefits to over 34 million Provide health benefits to over 34 million Americans in all 50 statesAmericans in all 50 states

Members and and their employees spend Members and and their employees spend billions on health care each yearbillions on health care each year


Their mission is to trigger a giant “LEAP” Their mission is to trigger a giant “LEAP” forward in quality, customer service and forward in quality, customer service and affordability of health care byaffordability of health care by ““Making the American public aware of a Making the American public aware of a

small number of highly compelling and easily small number of highly compelling and easily understood advances in patient safety and”understood advances in patient safety and”

““Specifying a simple set of purchasing Specifying a simple set of purchasing principles designed to promote these safety principles designed to promote these safety advances, as well as overall customer value” advances, as well as overall customer value”


Their effort is rooted in four ideas:Their effort is rooted in four ideas: American health care remains “far American health care remains “far

below” obtainable levels of basic safety below” obtainable levels of basic safety and overall customer valueand overall customer value

The health care industry would improve The health care industry would improve more rapidly if purchasers better more rapidly if purchasers better recognized and rewarded superior recognized and rewarded superior safety and valuesafety and value


Voluntary adherence to purchasing Voluntary adherence to purchasing principles by a critical mass of America’s principles by a critical mass of America’s largest employers would provide a large largest employers would provide a large jump-start and encourage other purchasers jump-start and encourage other purchasers to jointo join

These principles should not only champion These principles should not only champion superior overall value but also focus on a superior overall value but also focus on a handful of specific innovations offering handful of specific innovations offering “great leaps” in basic patient safety to “great leaps” in basic patient safety to maximize media and consumer support and maximize media and consumer support and adoption by other purchasers. adoption by other purchasers.

The Leapfrog Group: The Leapfrog Group: WhatWhat

Initial Leaps in Patient SafetyInitial Leaps in Patient Safety Computer Physician Order Entry (CPOE)Computer Physician Order Entry (CPOE)

Shown to reduce errors in hospitals by more than Shown to reduce errors in hospitals by more than 50%50%

Evidence-Based Hospital Referral (EHR) Evidence-Based Hospital Referral (EHR) Patients risk of dying could be reduced by more than Patients risk of dying could be reduced by more than

30%30% ICU Physician Staffing (IPS)ICU Physician Staffing (IPS)

Shown to reduce the risk of patients dying in the Shown to reduce the risk of patients dying in the ICU by more than 10%ICU by more than 10%

The Leapfrog Group: The Leapfrog Group: WhatWhat

Recommendations regarding Critical CareRecommendations regarding Critical Care ICUs should be staffed by Board-certified ICUs should be staffed by Board-certified

intensivists, to coordinate and manage care of intensivists, to coordinate and manage care of patientspatients

Intensivists should staff ICUs during daytime Intensivists should staff ICUs during daytime hours, a minimun of 8 hours, 7 days a weekhours, a minimun of 8 hours, 7 days a week

Intensivists should respond to more than 95% Intensivists should respond to more than 95% of calls for assistance within 5 minutesof calls for assistance within 5 minutes

The intensivist, a FCCS certified physician or The intensivist, a FCCS certified physician or “physician extender” should arrive at the “physician extender” should arrive at the bedside within 5 minutes in 95% of casesbedside within 5 minutes in 95% of cases

The Leapfrog Group: The Leapfrog Group: Why Why

ICU Physician Staffing (IPS)ICU Physician Staffing (IPS) More than 4 million patients are admitted to More than 4 million patients are admitted to

ICUs each year in he US ICUs each year in he US 11

Mortality rates average 10 - 20 % in most Mortality rates average 10 - 20 % in most hospitals hospitals 22

Approximately 500,000 patients die in US ICUs Approximately 500,000 patients die in US ICUs each year each year 11

Quality varies widely across hospitals Quality varies widely across hospitals 33

1.1. Birkmeyer VD et al. Leapfrog safety standards: potential benefits of Birkmeyer VD et al. Leapfrog safety standards: potential benefits of universal adoption. The Leapfrog Group. Washington, DC: 2000universal adoption. The Leapfrog Group. Washington, DC: 2000

2.2. Zimmerman JE et al. Evaluation of APACHE III predictions of hospital Zimmerman JE et al. Evaluation of APACHE III predictions of hospital mortality in an independent database. Crit Care Med. 1998;26:1317-26.mortality in an independent database. Crit Care Med. 1998;26:1317-26.

3.3. Knaus WA et al. Variations in mortality and length of stay in intensive care Knaus WA et al. Variations in mortality and length of stay in intensive care

units. Ann Int Med. 1993;118:753-61units. Ann Int Med. 1993;118:753-61

The Leapfrog Group: The Leapfrog Group: WhyWhy

Evidence Based Medicine in the ICU:Evidence Based Medicine in the ICU: Drakulovic, et al. Supine body position as a risk Drakulovic, et al. Supine body position as a risk

factor for nosocomial pneumonia in mechanically factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet ventilated patients: a randomized trial. Lancet 1999;354: 1851.1999;354: 1851.

Cook, et al. A comparison of sucralfate and ranitidine Cook, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J in patients requiring mechanical ventilation. N Engl J Med 1998; 338: 791Med 1998; 338: 791

Attia, et al. Deep vein thrombosis and its prevention Attia, et al. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 2001; in critically ill adults. Arch Intern Med 2001; 161:1268161:1268

Pronovost et al. Improving Communication in the ICU Pronovost et al. Improving Communication in the ICU using Daily Goals. J Crit Care 2003;18 vol 2: 71-75using Daily Goals. J Crit Care 2003;18 vol 2: 71-75


Evidence Based Medicine in the ICU:(cont’d)Evidence Based Medicine in the ICU:(cont’d) Kress, et al. Daily interruption of sedative infusions in Kress, et al. Daily interruption of sedative infusions in

critically ill patients undergoing mechanical ventilation. critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471.N Engl J Med 2000; 342:1471.

E. Wesley Ely. Effects on the duration of mechanical E. Wesley Ely. Effects on the duration of mechanical ventilation of identifying patients capable of breathing ventilation of identifying patients capable of breathing spontaneouly. N Engl J Med 1996; 335: 1864.spontaneouly. N Engl J Med 1996; 335: 1864.

Herbert, et al. A multicenter, randomized, controlled trial Herbert, et al. A multicenter, randomized, controlled trial of transfusion requirements in critical care. N Engl J Med of transfusion requirements in critical care. N Engl J Med 1999; 340: 409.1999; 340: 409.

Wu, et al. Blood transfusion in elderly patients with acute Wu, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345:1230.myocardial infarction. N Engl J Med 2001; 345:1230.

Van den Berghe, et al. Intensive insulin therapy in Van den Berghe, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359critically ill patients. N Engl J Med 2001; 345: 1359


Evidence Based Medicine in the ICU:(cont’d)Evidence Based Medicine in the ICU:(cont’d) Brown, et al. Effect of ICU mortality of a full-time critical Brown, et al. Effect of ICU mortality of a full-time critical

care specialist. Chest. 1989;96:127-129 (ICU mort from care specialist. Chest. 1989;96:127-129 (ICU mort from 27.8% to 13.4%, hospital mortality from 35.5% to 24.5%)27.8% to 13.4%, hospital mortality from 35.5% to 24.5%)

Manthous, et al. Effects of a medical intensivist on Manthous, et al. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo patient care in a community teaching hospital. Mayo Clin Proc. 1997;72:391-399 (Hospital mortality from Clin Proc. 1997;72:391-399 (Hospital mortality from 34% to 25 %, hospital stay reduced by 5 days, improved 34% to 25 %, hospital stay reduced by 5 days, improved housestaff knowledge)housestaff knowledge)

Hanson, et al. Effects of an organized critical care Hanson, et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274 (No effect on study. Crit Care Med. 1999;27:270-274 (No effect on mortality; fewer complication (0.5 vs 1.7 per patient); mortality; fewer complication (0.5 vs 1.7 per patient); shorter ICU ( 2 vs 2.8 days) and hospital ( 20.3 vs 23.6 shorter ICU ( 2 vs 2.8 days) and hospital ( 20.3 vs 23.6 days) stay; lower cost ($34,500 vs $47,500)days) stay; lower cost ($34,500 vs $47,500)


Review of published data regarding Review of published data regarding IPS in the Feb 2004, Am J Med:IPS in the Feb 2004, Am J Med: Many of the Leapfrog group’s standards Many of the Leapfrog group’s standards

for critical care are not grounded for critical care are not grounded sufficiently in evidence to mandate their sufficiently in evidence to mandate their implementationimplementation

Outcomes of critically ill patients Outcomes of critically ill patients areare better when their care is managed better when their care is managed directly or with the help of intensivists directly or with the help of intensivists 11

Pronovost et al. Physician staffing patterns and clinical outcomes in critically ill patients. A Pronovost et al. Physician staffing patterns and clinical outcomes in critically ill patients. A systematic review. JAMA. 2002;6:2151-2162.systematic review. JAMA. 2002;6:2151-2162.

The Leapfrog Group: The Leapfrog Group: Where Where

Wave 1 - 2001Wave 1 - 2001 Atlanta, GAAtlanta, GA CaliforniaCalifornia Knoxville TNKnoxville TN Minneapolis, MNMinneapolis, MN St. Louis, MOSt. Louis, MO Seattle, WASeattle, WA MichiganMichigan

The Leapfrog Group: The Leapfrog Group: WhereWhere Wave 2 - 2002Wave 2 - 2002

Central FloridaCentral Florida ColoradoColorado Dallas-Fort Worth, TXDallas-Fort Worth, TX Kansas City, MOKansas City, MO WisconsinWisconsin MassachusettsMassachusetts Memphis, TNMemphis, TN New JerseyNew Jersey New York MetroNew York Metro Rochester, NYRochester, NY Savannah, GASavannah, GA Wichita, KSWichita, KS

The Leapfrog Group: The Leapfrog Group: WhereWhere

Wave 3 - 2003Wave 3 - 2003 Hampton Roads, VAHampton Roads, VA IllinoisIllinois MaineMaine

The Leapfrog GroupThe Leapfrog Group As of October 2003:As of October 2003:

Over 1000 hospitals voluntarily participated in the Over 1000 hospitals voluntarily participated in the online survey to report their progress towards online survey to report their progress towards implementing the recommended practicesimplementing the recommended practices

5% of hospitals in the regional roll-outs report 5% of hospitals in the regional roll-outs report they have implemented CPOE, and an additional they have implemented CPOE, and an additional 17% committed to implement CPOE by 200517% committed to implement CPOE by 2005

21% have implemented ICU Physician Staffing and 21% have implemented ICU Physician Staffing and an additional 5.4% have committed to by 2004an additional 5.4% have committed to by 2004

80% of health care consumers in the US now have 80% of health care consumers in the US now have access to patient safety data for one or more access to patient safety data for one or more hospitals in their areahospitals in their area

The Leapfrog Group: The Leapfrog Group: DFWDFW

DFWBGH is the local representativeDFWBGH is the local representative 3 workgroups made up of system 3 workgroups made up of system

administrators, system administrators administrators, system administrators and DFWBGH membersand DFWBGH members ICU outcomesICU outcomes CPOECPOE Evidence based referralEvidence based referral

Meeting for about 1 year and have Meeting for about 1 year and have accomplished ????????accomplished ????????

The Leapfrog GroupThe Leapfrog Group

QUESTIONS?QUESTIONS?

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Leapfrog Who, What, Why, Where,When Gary L. Weinstein M.D. Director of Pulmonary and Critical Care Presbyterian Hospital of Dallas