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Use of TeleMedicine to Improve Clinical and Financial Outcomes
Michael Ries, MD, MBA, FCCM, FCCP, FACPMedical Director, Critical Care and eICU
Advocate Health CareNovember 12, 2015
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)
Objectives
3
• 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)
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
Advocate Critical Care
5
• 18 ICU’s• 12 hospitals• Five Level 1 Trauma Centers• > 6000 physicians• > 100 Intensivists• 301 Critical Care beds (not including our Outreach programs + 100 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= 0.50–0.60 (in 2010 = 0.72)
IT
StrategyCulture
6
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
The Goal
Improve The Quality of Care We Provide To Our Critical Care Patients and Reduce Costs
8
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
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
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
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
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
Tele ICU Experience – InterventionsClinically Significant
Intervention Number Percentage
Best Practice Adherence 1625 14%
Comprehensive Adm Review 1134 10%
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 69 0.6%
Lilly J In Care Med 2009
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
“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)
eICU Report Sheet
17
Ventilator Associated Pneumonia(VAP) Bundle Assessment Screen
18
19
All ICU UnitsVent Days 470 558 525 525 454 354 403 532 258Compliant Vent Bundles 445 95% 539 97% 502 96% 499 95% 444 98% 337 95% 381 95% 515 97% 254 98%Non-Compliant Bundles 25 19 23 26 10 17 22 17 4
Non-Compliant for Sedation Vacation 3 2 7 6 2 1 3 6 3Non-Compliant for Assess Extubation Readiness 0 1 2 5 0 1 0 1 0Non-Compliant for GI Bleed Prophylaxis 12 4 7 4 6 2 9 7 1Non-Compliant for DVT Prophylaxis 10 10 6 10 3 11 9 6 0Non-Compliant for HOB30 PM 0 0 0 2 0 1 2 0 0Non-Compliant for HOB30 AM 1 3 4 2 0 6 2 0 1
CMC MICCUVent Days 73 79 66 72 52 40 63 96 24Compliant Vent Bundles 70 96% 74 94% 65 98% 67 93% 52 100% 40 100% 57 90% 96 100% 23 96%Non-Compliant Bundles 3 5 1 5 0 0 6 0 1
Non-Compliant for Sedation Vacation 0 1 0 1 0 0 0 0 1Non-Compliant for Assess Extubation 0 0 1 0 0 0 0 0 0Non-Compliant for GI Bleed Prophylaxis 0 0 0 1 0 0 3 0 0Non-Compliant for DVT Prophylaxis 3 3 0 2 0 0 2 0 0Non-Compliant for HOB30 PM 0 0 0 0 0 0 0 0 0Non-Compliant for HOB30 AM 0 1 0 1 0 0 1 0 0
4Q2011 1Q2012 2Q2012
VAP compliance (25 months rolling) Components contributing to Non-Compliance in Ventilator Bundle (3 months)
4Q2013
No Non-Compliant items over the last 3 months
VAP Compliance CMC MICCU
2Q2013 3Q20131Q20134Q20123Q2012
Date
Pro
port
ion
1.0
0.9
0.8
0.7
0.6
_P=0.9793UCL=1
LCL=0.8922
Count 1 0Percent 100.0 0.0Cum % 100.0 100.0
Count
Perc
ent
Type OtherSedation Vacation
1.0
0.8
0.6
0.4
0.2
0.0
100
80
60
40
20
0
20
ICU VAP: Avoided Cost Trend
•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
All ICU Units
DVT Days 6458 6328 6080 6844 6246 6194 6589 5868 6310DVT Compliant 6293 97% 6137 97% 5901 97% 6661 97% 6096 98% 6036 97% 6489 98% 5751 98% 6207 98%No prophlaxis 165 191 179 183 150 158 100 117 103Compliant via Contra-indication 528 500 521 499 550 498 629 566 570
Type of Prophlaxis Mechanical 2431 42% 2411 43% 2182 41% 2488 40% 2135 38% 2162 39% 2245 38% 2139 41% 2110 37% Pharmicalogical 1510 26% 1409 25% 1611 30% 1604 26% 1494 27% 1543 28% 1646 28% 1498 29% 1731 31% Combined theropy 1824 32% 1817 32% 1587 29% 2070 34% 1917 35% 1833 33% 1969 34% 1548 30% 1796 32%
CMC MICCU
DVT Days 579 553 576 642 589 624 639 553 616DVT Compliant 574 99% 546 99% 568 99% 632 98% 580 98% 614 98% 633 99% 552 100% 610 99%No prophlaxis 5 7 8 10 9 10 6 1 6Compliant via Contra-indication 78 44 53 42 50 49 69 82 84
Type of Prophlaxis Mechanical 171 34% 163 32% 164 32% 127 22% 124 23% 140 25% 114 20% 148 31% 164 31% Pharmacological 279 56% 275 55% 277 54% 356 60% 351 66% 370 65% 373 66% 269 57% 320 61% Combined therapy 46 9% 64 13% 74 14% 107 18% 55 10% 55 10% 77 14% 53 11% 42 8%
Dec-09 Jan-10
DVT Compliance (25 months rolling) Type of prophlaxis used
DVT Compliance CMC MICCU
Feb-10 Mar-10Jul-09 Aug-09 Sep-09 Oct-09 Nov-09
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Dec-09 Jan-10 Feb-10 Mar-10 All ICU Units
Combinedtherapy
Pharmacological
Mechanical
current month
1.00
0.95
0.90
0.85
0.80
0.75
0.70
_P=0.9859
UCL=1
LCL=0.9716
21
22
23
Sepsis Hospital Mortality Index
24
Data reflected is subject to roundingData Source: APACHE IVa/ 3Q14, 4Q14, 1Q15,
2Q15Target Index not benchmarked by Philips
Target Index not benchmarked by Philips
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
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
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
Connect the Process to the Outcomes
28
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
KRA Target Overview and Weights Measure Min Target Max Weight
67%
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%
Culture of Safety Survey Percentile 50th 75th 90th 10.0%
33%
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
Ventilator Day Improvement SummaryHealth outcomes results:• 1938 fewer vent days 3Q13 vs 4Q11
– 265 fewer ICU days • 7.4 pts given Sedation Vacation and SBT saves one life
– Advocate = 828 lives savedTotal cost savings:
– Represents $1.35M**Savings assumes ICU vent day substituted with Med/Surg Day
0.000.200.400.600.801.001.201.401.60
2009 2010 2011 2012 2013
ICU Mortality APACHE Predicted
Ac
tual
/Pre
dict
ed M
orta
l-ity
31
1.18
1.03
1.17
1.28 1.301.26
1.15
1.08
1.04 1.02
0.95
0.88 0.89
0.85
0.81
0.870.84
0.92
0.800.83
0.79
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
(A/P
) V
en
t D
ays
2009-Q3 2010-Q3 2011-Q3 2012-Q3 2013-Q3 2014-Q3
Hosp DC Yr & Qtr
2014 Q4 - ADVOCATE HEALTH CARE
APACHE IVa Ventilator Days Ratio
34
ICU CLABSI: Avoided Cost Trend
•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
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
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
ED Boarders 2014
Grand Total Admit to ICU January 6698
February 3130
March 71579
April 94872
May 81821
June 64763
July 73933
August 109936
September 64759
October 65752
November 93092
December 106195
Grand Total 6058143 836530
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.
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.
Cause Map
e
MICCU residents work under intensivists
who do not see patients before admit
to MICCU
Patient Safety Goal
Impacted
Cardiogenic shock
Patient hemodynamic
unstable
Intensivist/ Resident from
MICCU not involved in patient care in ED
Delay in diagnosing
STEMI
Delay in cardiac cath
Death
Significant myocardial
injury
No beds available
Limited treatment options for
cardiac condition
Pt admitted to MICCU and
holding in ED
Patients awaiting bed availability to
transfer from MICCU.
Lack of available beds due to census.
No ICU protocols utilized in ED
ED physicians cannot write admit orders
No admitting orders written on ICU holds in
ED.
No repeat labs/EKGs ordered
Credentials do not allow
Patient not seen in ED by attending or
MICCU docs/residents
Too busy with MICCU patients
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
ICU Admission Boarding in ED WorkflowICU patient is ED, ICU bed
needed
Physician places ICU bed request after “Dr. Done”
Bed request to Bed Board
eICU receives text page from
bed board
ED notified by bed board that
ICU bed not available
Desk clerk places patient into “ICU Virtual Hold Bed”
ECC5, ECC6, ECC7, ECC8
MICCU bed not available if less than 2 open beds
Patient is admitted as Inpatient status
eCare Mobile Cart activated & eAlert button pressed by
ED RN
ED staff notifies eICU of admission Contact info
from faxed eICU Assignment Sheet for ED
RN1. Name2. Patient ID (MRN)3. Diagnosis4. Attending Intensivist5. ED room number6. 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
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
Page initiated by resident
Call in to Tie-Line for hand-over
PhysicianeICU RN Intensivist +/-Attending
ED Resident RN
ED notifies eICU of transfer to MICCU
bed by eAlert
2/2015 3/2015 4/2015 5/2015 6/2015 7/2015 8/2015 9/2015 10/2015 FEB-OCT0
20
40
60
80
100
120
140
160
180
200
220
240
260
280
Dow
ngra
de; 6
Dow
ngra
de; 8
Dow
ngra
de; 7
Dow
ngra
de; 2
2
Dow
ngra
de; 1
6
Dow
ngra
de; 2
3
Dow
ngra
de; 7
Dow
ngra
de; 3
Dow
ngra
de; 5
Dow
ngra
de; 9
2
ICU;
20
ICU;
13
ICU;
9
ICU;
27
ICU;
33
ICU;
31
ICU;
29
ICU;
7 ICU;
18
ICU;
169
Gran
d To
tal;
26
Gran
d To
tal;
21
Gran
d To
tal;
16 Gran
d To
tal;
49
Gran
d To
tal;
49
Gran
d To
tal;
54
Gran
d To
tal;
36
Gran
d To
tal;
10
Gran
d To
tal;
23
Gran
d To
tal;
261
Monthly eMobile Cart Count by Discharge to ICU vs Downgrade
Monthly eMobile Cart Count by Discharge to ICU vs Downgrade
2/2015 3/2015 4/2015 5/2015 6/2015 7/2015 8/2015 9/2015 10/2015 FEB-OCT0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Dow
ngra
de; 2
3% Dow
ngra
de; 3
8%
Dow
ngra
de; 4
4%
Dow
ngra
de; 4
5%
Dow
ngra
de; 3
3%
Dow
ngra
de; 4
3%
Dow
ngra
de; 1
9%
Dow
ngra
de; 3
0%
Dow
ngra
de; 2
2% Dow
ngra
de; 3
5%
ICU;
77%
ICU;
62%
ICU;
56%
ICU;
55%
ICU;
67%
ICU;
57%
ICU;
81%
ICU;
70%
ICU;
78%
ICU;
65%
Monthly eMobile Cart Percent by Discharge to ICU vs Downgrade
Feb Mar Apr May Jun Jul Aug Total
2014 ER to ICU LOS 3130 71579 94872 81821 64763 73933 109936 500034
2015 eMobile LOS 7219.00000002002 25869.9833333341 4882.00000000885 23933.0000000296 26419.0000000235 31627.9999999877 14247.9999999865 134198.98333339
50000
150000
250000
350000
450000
550000
Comparison: 2014 ER to ICU LOS vs 2015 eMobile LOS
2014 ER to ICU LOS 2015 eMobile LOS
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
eICU Associate Satisfaction Trends
48
Fall 2005
Spring 2006
Fall 2006
Spring 2007
Fall 2007
Spring 2008
Fall 2008
Spring 2009
Fall 2009
Spring 2010
Fall 2010
Spring 2011
Fall 2011
Spring 2012
Fall 2012
Spring 2013
Fall 2013
0
10
20
30
40
50
60
70
80
90
100
63
28
1
10
1 1
58
16
2
97 97
67
97
67
79
99 99
Percentile Ranking
Percentile Ranking
Objectives
49
• 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)
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)
