Critical Care Research: Connection to Practice

Abbott Northwestern Hospital Innovation Summit November 5, 2016

Roman Melamed, MD, FCCP

PE PATIENT CARE COORDINATIONReferring hospitalTelemetr

y ICU

ED Hospitalist

Crit ical Care

IR

Cardiology

Hematology

Thoracic surgery

Courtesy of Dr. Bjorn Engstrom

Critical Care Research Program Goals

• Conduct research studies pertinent to the practice of critical care and hospitalist medicine at ANW that will improve patient outcomes, enhance quality of care and care coordination, and reduce costs• Generate peer-reviewed publications and presentations at regional, national, and

international meetings, as well as best practice guidelines and protocols• Contribute to the attraction and retention of world-class providers by offering an

environment that promotes and supports investigator-initiated research• Convene investigators regularly to review and prioritize new study proposals,

examine progress of ongoing studies, and provide support and advice to investigators

Critical Care Research Program

Participants•Intensivists•Hospitalists•Med Education•ED, Cardiology, Pulmonary, IR, Pain Service, CV Surgery•Clinical Pharmacy

Clinical Units

•Med/Surg ICU•Neuro ICU•CV ICU•Hospital units

Partners•Division of Applied Research•ANW Foundation•ICU QI specialists and CNS•MHI Research

High Risk = enhanced monitoring and treatment team notification + continuous capnography/oxymetry device

Moderate Risk = enhanced monitoring and treatment team notification

Standard Risk = standard ortho unit monitoring protocol

ANW Postoperative Patient Monitoring Algorithm Proposal

Portable CXR: low sensitivity and specificity, frequently non-diagnostic

Chest CT: need to transport to radiology, radiation exposure, cost

US Consolidation

US Effusion

US Consolidation

US Interstitial Pattern

Pulmonary US Scoring System

Pulmonary Ultrasound Scoring System for Intubated Critically Ill Patients and its Association to Clinical Metrics and Mortality*

*Manuscript submittedPI Dr. D. Tierney

Pulmonary Ultrasound Scoring System for Intubated Critically Ill Patients and its Association with Clinical Metrics and Mortality*

*Manuscript submittedPI Dr. D. Tierney

Annual Cardiovascular-Thoracic Critical Care Conference, Washington DC, September 2016

• Mandatory intensivist integration was associated with

Reduced Post-op ventilator time

Shorter length of stay Lower rates of re-

operations for bleeding Lower rates of

encephalopathy Decrease in total cost

Impact of Mandatory Intensivist Consult after Cardiac Surgery

Table 2. Post-Operative Outcomes by Staffing Model

Variables Elective Intensivist(n=672)

Mandatory Intensivist

(n=773)p-valuea

Post-Operation Ventilation Time, hours

5.6 (3.6-11.3) 3.8 (2.2-6.9) <0.001

Length of Stay, days ICU 1.2 (1-2) 1.1 (0.9-2) <0.001 Post-Operation 6.1 (5-8) 5.7 (5-7) <0.001 Hospital Stay 7 (5-10) 6 (5-9) <0.001

Costsb, USD

Variable 21644 (18050-28140) 20309 (17210-25652) <0.001

Fixed 10048 (8173-13923) 9277 (7602-12550) <0.001

Total 31399 (26474-41714) 29517 (24903-38429) <0.001

Complications (30 days post-operation) 53% (356) 48% (371) 0.07

Stroke (Permanent) 4% (24) 2% (16) 0.12

Renal Failure 1.8% (12) 1.4% (11) 0.68 Sepsis 1.2% (8) 0.3% (2) 0.05 Re-op Bleeding 5% (33) 2% (15) 0.002 Encephalopathy 4% (27) 1% (6) <0.001 Readmission to ICU 4% (27) 4% (30) 0.89

Infection, Use of Antibiotics and Outcomes in Patients Receiving Therapeutic Hypothermia

After Cardiac Arrest*

*Manuscript preparationPI Dr. J. Huelster

Variable

All Patients(n = 248) Intra-TH Antibiotics

(n = 184) Post-TH Antibiotics(n = 64)

p value Any infection, % (n) 74% (184) 72% (132) 81% (52) 0.13 Infection Type*, % (n) Pneumonia 59% (146) 57% (104) 66% (42) 0.20 Sepsis/bloodstream 28% (69) 30% (55) 22% (14) 0.22 Urinary tract 8% (20) 6% (11) 14% (9) 0.04 Cellulitis 2% (4) 1% (2) 3% (2) 0.28** None 26% (64) 28% (52) 19% (12) 0.13 ICU LOS, days 6.9 (2.6 - 54.6) 6.3 (2.6 - 54.6) 7.3 (2.8 - 27.9) 0.14***

Hospital LOS, days 10 (3 - 71) 10 (3 - 55) 12 (3 - 71)

<0.001*** Mechanical ventilation, hrs 120 (34 - 1301) 120 (34 - 1301) 119 (39 - 639) 0.90***

CPC at discharge, % (n)

CPC 1 32% (80) 27% (50) 47% (30)

CPC 2 26% (64) 26% (47) 27% (17)

CPC 3 6% (15) 6% (11) 6% (4)

CPC 4 2% (6) 2% (4) 3% (2)

CPC 5 33% (83) 39% (72) 17% (11)

Inhospital mortality, % (n) 33% (83) 39% (72) 17% (11) 0.001

STUDY INVESTIGATORS CLINICAL IMPACTSystemic and catheter-directed thrombolysis for pulmonary embolism

ANW Intensivist Service, DAR, Hospitalists TPA for PE order set; Severe PE Management Algorithm; PE Response Team

Respiratory failure in orthopedic surgery patients

ANW Intensivist Service, DAR, IM Residency, Pharmacy, Pain Service

Recommendations on triage and management of postoperative orthopedic surgery patients

Pulmonary ultrasound scoring system for intubated ICU patients

IM Residency, DAR, Hospitalists Introduction of a new pulmonary ultrasound imaging technique in ANW ICU

Antibiotic use and infection in therapeutic hypothermia

ANW Intensivist Service, DAR, MHI/Cardiology

Inform best practices of antibiotic use in post-cardiac arrest patients

Neuroprognostication in therapeutic hypothermia

MN Epilepsy/Neurology, ANW Intensivist Service, DAR, Noran Clinic

Provide clinicians with data that enhance prediction of neurologic prognosis in post-cardiac arrest patients

Impact of mandatory intensivist consultation after cardiac surgery

ANW Intensivist Service, DAR, MHI/Cardiology

Identify opportunities to improve outcomes in post-cardiac surgery patients

Hemodynamics in Therapeutic Hypothermia

MHI/Cardiology, ANW Intensivist Service, DAR, Hospitalists

Understand the performance of different methods of cardiac output measurement in hypothermia patients

Complications and outcomes in ICU patients with neurologic diagnosis

ANW Intensivist Service, DAR, ANW Neuro-IR

Analyze ANW-specific neuro ICU patient population and identify opportunities to improve outcomes

Validation of clinical deterioration tool

ANW Intensivist Service, DAR Prediction of clinical deterioration in a hospitalized patient

ICU Patient Registries ANW Intensivist Service, DAR, Health Catalyst

Organize and use clinical data to improve ICU outcomes

Available on ANW Intensivist Website

Clinical Dilemma

Research Protocol

• Practice recommendations• Order sets• New clinical programs

Abstract/poster at regional, national and international conferences

• Improved outcomes• Improved care coordination• Reduced costs

• Peer-reviewed publication• Patient registry• Funding sources

ClinicalImpact

BuildResearch Capacity

Critical Care Research