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WelcomeAdvisor Live® Webinar: April 11, 2018Our Presentation:Improving ICU Utilization: Developing an Action PlanWill Begin Shortly

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Advisor Live® WebinarImproving ICU Utilization: Developing an Action Plan

April 11, 2018

Listen to Today’s Audio: 888.223.4671

Download today’s slides at www.premierinc.com/events


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QUESTIONSUse the “Questions and Answers”

RECORDINGThis webinar is being recorded. View it later today on the event post at premierinc.com/events.

NOTESDownload today’s slides from the event post at premierinc.com/events


Speakers

Robin Czajka, RNService Line Vice President, Cost ManagementPremier

Cindy SalyerDirector, Premier Performance PartnersPremier

Jeffrey Wright, PhD, MDPhysician in Pulmonary and Critical CareBaptist Memorial Health Care, Memphis, TN

Maria Zhorne, PharmD, BCCCPCritical Care Clinical Pharmacy SpecialistBaptist Memorial Health Care, Memphis, TN


Polling Question

What do you think your ICU’s greatest opportunity for improvement is?

1. Reducing cost

2. Improving throughput

3. Improving quality


Imperative


Imperative

Intensive Care Unit (ICU) Utilization

• Over 5.7 million patients are admitted into the ICU annually1

• Approximately 55,000 critically ill patients are cared for each day in the United States1

• In 2011, 26.9% of hospital stays involved ICU charges2

• ICU costs represent 20% of total inpatient costs2

• Hospital stays that involve ICU services are 2.5 times more costly than other hospital stays2

3


Imperative

4

4


Imperative

The adoption of published, effective, clinical interventions into routine patient care is significantly lagging. One U.S survey found5:

33%Intensivists use a

valid delirium screening tool

40%ICU providers reported using spontaneous

breathing trials

30-40%ICU providers

manage sedation without a sedation

monitoring instrument

<2%Intubated patients were mobilized out of bed during their

ICU stay


• Decreased cognitive abilities

• Post-traumatic stress disorder

• Anxiety

• Depression

• Chronic pain

• Lower overall quality of life

• Preventable readmissions

• Negative effects extending to patient family members and caregivers

• Increased ICU and total LOS

• Increased complications and hospital-acquired conditions

• Decreased patient and family satisfaction

• Increased cost of care

• Decreased bed availability

Short-term Long-term

Imperative

What impact does a prolonged ICU stay have on your patients?5

6


Polling Question

Which of today’s webinar objectives is most important to you? Learning how to:

1. Identify opportunities by leveraging data

2. Developing a project improvement work plan

3. Creating a compelling project improvement business case for leadership


Identify Opportunities


• Identify key performance indicators– Quality– Operational – Patient satisfaction

• Identify data sources

• Establish baseline opportunity

• Review – Savings opportunity identified by

service line/DRG– Performance improvement initiatives

aimed at improving patient throughput– Current metrics and trended performance

• Categorize– Opportunities for improvement – Available data

Identify Opportunities


Identify Opportunities – Metrics that reveal opportunity days

Total length of stay (LOS) by level of care (LOC)

ICU utilization – LOS by LOC and percentage of patients admitted

ICU and step-down unit utilization by service line

ICU and step-down unit utilization by DRG

Benchmark:

ICU and step-down unit utilization by DRG by physician or physician practice

ICU and step-down unit utilization at patient level

Compare observed and expected:


Create a Business Case for Leadership



Key elements

• Outline imperative

• Calculate savings

• Examine clinical processes and outcomes

• Identify operational process opportunities for improvement

• Develop a work plan with defined project scope, core strategies, metrics and milestones

• Determine specific initiatives to achieve defined targets

• Standardize clinical practice utilizing evidence-based practice guidelines

Evidence indicatesthat a majority of care

providers have not adopted standardized

processes in ICU for pain, minimal sedation and

early mobility5

96% of C-suite survey respondents ranked

reducing clinical variation and standardizing

products, resources and services as a top cost management priority7


LOC/LOS Opportunity Approach

LOC/LOS utilization opportunity analysis considers:• First: Identification of variability in level of care compared to peers

– Quantified number of patients placed on a higher level of care at a greater frequency than the peer group

• Second: Quantified savings opportunity in moving these patients to the next level of care:– Critical Care (ICU/CCU) to Step Down– Step Down to Med/Surg

• Opportunity analysis conducted at the DRG level, then aggregated

Current State

Current State

Appropriate Use

Appropriate Use

Qua

ntity

of C

ases

(by

DR

G)

Critical Care (ICU/CCU) Step Down

Variability Opportunity Variability

Opportunity

LOC/LOS Opportunity


Resource Utilization – LOC/LOS Example

Top 10 MS-DRGs Cases

Critical Care

Cases

Critical Care Days

Facility ICU

ALOS

Peer ICU

ALOS

Facility ICU

Utilization

ICU Peer Utilization Rate (%)

292 Heart failure & shock w CC 82 6 11 1.83 2.44 7.31% 4.46%

190 Chronic obstructive pulmnry disease w MCC 114 11 25 3.02 2.97 9.6% 10.59%

287 Circ disordrs exc AMI, w crd cath w/o MCC 84 18 32 1.77 1.64 21.4% 8.71%

247 Perc crdvsc PX w drug-elut stent w/o MCC 116 49 74 1.51 1.29 42.2% 35.99%

291 Heart failure & shock w MCC 69 18 46 2.56 3.25 66.7% 19.35%

310 Card arrhyth&conduct disorders w/o CC/MCC 88 7 9 1.29 1.76 8.0% 8.96%

193 Simple pneumonia & pleurisy w MCC 76 16 44 2.75 3.06 21.1% 16.86%

65 Intracrnial hem or cerebral infarct w CC 56 9 18 2.00 2.84 16.1% 20.15%

392 Esophagitis, GI&msc digst disordr w/o MCC 179 5 6 1.20 2.18 2.8% 3.43%

309 Card arrhythmia & conduct disorders w CC 44 6 7 1.17 1.81 13.6% 13.60%

Critical Care Comparison to Benchmarks8


Resource Utilization – LOC/LOS Example

Stepdown Comparison to Benchmarks8

Top 10 MS-DRGs Cases Stepdown

CasesStepdown

Days

Facility Stepdown

ALOS

Peer Stepdown

ALOS

Facility Stepdown Utilization

Stepdown Peer

Utilization Rate (%)

292 Heart failure & shock w CC 82 74 303 4.09 2.44 90.2% 20.88%

190 Chronic obstructive pulmnry disease w MCC 114 63 190 3.02 3.34 55.3% 10.72%

287 Circ disordrs exc AMI, w crd cath w/oMCC 84 78 223 2.86 2.19 92.9% 32.75%

247 Perc crdvsc PX w drug-elut stent w/o MCC 116 100 228 2.28 1.79 86.2% 31.18%

291 Heart failure & shock w MCC 69 50 211 4.22 3.97 72.5% 22.45%

310 Card arrhyth&conduct disorders w/o CC/MCC 88 82 163 1.99 1.69 93.2% 31.69%

193 Simple pneumonia & pleurisy w MCC 76 44 151 3.43 4.28 57.9% 12.94%

65 Intracrnial hem or cerebral infarct w CC 56 39 132 3.38 2.76 69.6% 18.11%

392 Esophagitis, GI&msc digst disordr w/o MCC 179 66 129 1.95 2.21 36.9% 6.16%

309 Card arrhythmia & conduct disorders w CC 44 44 126 2.86 2.31 100.0% 30.34%


LOC and LOS: Identify Service Lines with Greatest Opportunity – Example8

MS-DRG Business Line

Total Cases

RUM Total Opportunity

LOC Total Opportunity

LOS Total Opportunity

Total Cost Opportunity

Total Cost Opportunity as % of Total

Target: 50% of Total Cost

Opportunity

Target: 50% of Total Cost

Opportunity/ Case

General Surgery 2,397 $4,441,500 $1,475,800 $2,114,800 $8,026,500 27% $4,013,250 $1,674

Neonatology 3,147 $639,700 $3,450,000 $2,059,600 $6,149,300 21% $3,074,650 $977

General Medicine 7,607 $1,838,900 $320,800 $2,125,100 $4,284,200 14% $2,142,100 $282

Cardiac Surgery 732 $1,114,200 $220,600 $682,500 $2,017,100 7% $1,008,550 $1,378

Neurology 1,283 $294,200 $478,900 $590,600 $1,362,900 5% $681,450 $531

Orthopedics 1,862 $646,200 $256,000 $377,500 $1,278,100 4% $639,050 $343

Psychiatry 1,244 $52,200 $11,000 $1,186,000 $1,249,200 4% $624,600 $502

Obstetrics 3,182 $147,800 $22,900 $633,800 $804,600 3% $402,300 $126

Cardiology 1,203 $317,400 $53,000 $430,800 $801,200 3% $400,600 $333

Trauma 717 $306,800 $160,000 $295,100 $763,100 3% $381,550 $532

Vascular Surgery 353 $307,600 $219,000 $152,800 $678,600 2% $339,300 $961

Neurosurgery 439 $257,600 $177,000 $147,800 $581,400 2% $290,700 $662

Orthopedics-Spinal 668 $411,700 $52,000 $66,600 $531,300 2% $265,650 $398

Hematology/Oncology 633 $95,000 $4,000 $230,700 $329,700 1% $164,850 $260

Thoracic Surgery 176 $116,100 $4,000 $113,000 $233,100 1% $116,550 $662

Medical Oncology 238 $53,800 $32,000 $130,300 $216,100 1% $108,050 $454

ENT 261 $34,900 $13,900 $96,600 $145,400 0% $72,700 $279

Trauma-Other 136 $74,200 $54,500 $16,000 $143,700 0% $71,850 $528

Urology 219 $57,100 $14,900 $65,400 $137,400 0% $68,700 $314

Surgical Oncology 135 $64,600 $0 $39,600 $104,200 0% $52,100 $386

Total 26,632 $11,271,500 $7,020,300 $11,554,600 $29,837,100 100% $14,918,550 $560

82% of opportunity is within the top 7 Service Lines



Identify adherence to clinical performance indicators and care bundle components including but not limited to:

ABCDEFBundle

ICU PAD Care

BundleCAUTI CLASBI VAP



Identify key team members to participate in an ICU utilization performance improvement team

Departments Physicians

CMO

Department Chairs

Existing Committee Structure

Critical Care

Intermediate/Step-down Units

Med/Surg Units

Behavioral Health

Emergency Services

EVS

Bed Placement Coordinator

CareManagement

IT

Decision Support



Summarize improvement opportunity impact

Quality Value Patient Satisfaction


Develop and Execute a Work Plan


Brainstorm/Capture Opportunities for Improvement


Analyze data to identify opportunities for improvement

Review data, educate team members and physicians

Implement standardized Multidisciplinary Team

Rounds (MDTR)

Review/revise Admission, Discharge, and Triage criteria (ADT)

Implement patient placement algorithms and patient acuity grids

Review/revise approved order sets/protocols/

bundles

Identify opportunity to build additional order sets/protocols/bundles; review supporting literature, engage physician champions and subject

matter leaders to develop and implement those order sets/protocols/bundles supported by the team

Identify and address operational process barriers which delay patient transfers

Review/revise care management model

Ensure early identification and plan to address

discharge needs

Streamline discharge processes

Assess community resource availability to meet patient discharge

needs/address identified barriers

Brainstorm/Capture

Opportunities for Improvement



Engage physicians to assist/identify operational issues that delay patient transfers; share findings with facility leadership, follow-up on recommendations and communicate with peers

Identify current physician committees which could be utilized to drive improvement activity. Examples: critical care, hospital medicine, cardiology, surgery, and/or internal medicine section meetings

Identify physician champions to lead improvement teams for specific areas of focus. Examples: ABCDEF, PAD, septicemia, heart failure, ventilator bundles• Update or develop evidence-based order sets and care bundles• Participate in small tests of change to implement specific initiative processes• Share initiative recommendations with MEC and at quality and physician section meetings• Improve operational processes



• Define team purpose and the scope, core strategies and key milestones

• ICU utilization team reviews data & identifies specific initiatives with accountable leaders and timeline. Focus on work for next 90 days

Activity Number Activity Lead(s) Support/

Resources Status Activity MonthlyUpdate

Due Date

Decisions Needed/Risks

1

Update benchmark data using best practice facility

peer

Melissa/Dan/ Michelle/

KeithCindy

Add facility data updated and

discussed internally3/20/18

2 Presentations for each region

Cindy/ Melissa Lexi/Michelle Facility leads by 3/30 4/1/18 Appropriate

system team

3

Develop LOC dashboard metrics with standardized

methodology

Ginny/ Eleanor/

Mary/ Jim

Cathy/ Appropriate

C-suite leaders

Communication plans are varied by facility –

Region III and V4/11/18



Most appropriate methods for communicating progress to medical

staff, administration and team members an on-going basis

Process for review of outlier diagnoses (trended), and cases by

unit and by physicians


Baptist Memorial Hospital


ICU Optimization Efforts toBenefit Patients’ Outcomes andGenerate Savings Through the

Jeffrey Wright, PhD, MDMaria Zhorne, PharmD, BCCCP


ABCDEFBundle


Setting:

Why Tackle the ABCDEF Bundle?

• The ABCDEF Bundle was developed with the intent of aiding practitioners to implement the guidelines in an organized fashion

• In 2015, Baptist Memorial Hospital – Memphis’ medical/surgical and neuro intensive care units joined the ICU Liberation Collaborative to implement the ABCDEF Bundle

Included ~80 hospitals from across the United States & Puerto Rico

Prospective, observational, quality improvement study

Baseline data and compliance data collected: August 2015 – April 2017


A Assess, prevent and manage pain

B Both spontaneous awakening and breathing trials (SAT/SBT)

C Choice of analgesia and sedation

D Delirium prevention and management

E Early mobility and exercise

F Family engagement and empowerment

What is the ABCDEF Bundle?


Pre-ABCDEF Bundle Implementation Environment

SAT/SBT Protocols

Designated PT/OT’s but no ambulation of intubated patients

Lack of standard order sets for medication orders & monitoring parameters

Varying pain monitoring scales utilized

No formal delirium testing

Inter-professional rounds


Premier Data

Premier data was used for all project

baseline data

Premier data will be instrumental in

future spread initiatives

A custom report was

developed in PremierQualityAdvisor to

identify cost of caretrending for thepopulation andmortality rates


Process Improvements

• Streamlined pain assessment scales– Self Report: Numeric Rating Scale (NRS)– Behavioral Pain Scale: Critical Care Pain Observation Tool (CPOT)

• Formalized delirium testing– Confusion Assessment Method (CAM-ICU)

• Developed process for increasing mobilization of intubated patients

• Developed the ABCDEF Bundle Documentation Flowsheet– Utilized in the Electronic Medical Record (EMR)– Aided in monitoring bundle compliance

• Pain, Agitation and Delirium (PAD) Order Set

• Improved inter-professional rounding script


Challenges

Insurmountable amount of ongoing education

Staff resistance to workflow change

Consistent documentation to track compliance

Compliance reports post-collaborative


Successes!

Delirium reductionOf those who experienced delirium, a majority (75%) experienced two or fewer days

of delirium

Coma reductionA vast majority of patients ever comatose (74%) spent two or fewer days in a coma

Increased likelihood patients would be discharged alive from the hospital

Hospital survival pre-intervention: 73% Hospital survival post-intervention: 88%

Education to Baptist Memorial Healthcare System

“Top Team Performance Award: East Coast Collaborative”

p = 0.02


Successes!

Education to Baptist Memorial Healthcare System

“Top Team Performance Award: East Coast Collaborative”


Convincing the C-Suite

Initial buy-in

Creativity to utilize resources already available

Presenting the data • Pre-intervention data already published• Results from bundle implementation


Learning from Others

Collaborative effort with hospitals of all shapes & sizes

E-Community (Society of Critical Care Medicine)• Collaborative chat room to share ideas• Communicate successes and challenges

Regional Meetings• Beginning, middle and end of collaborative work


ICU Optimization Efforts to Benefit Patients’ Outcomes and Generate Savings Through the

ABCDEFBundle

Jeffrey Wright, PhD, MDMaria Zhorne, PharmD, BCCCP



Questions?


Polling Question

Would you be interested in learning how Premier can help you improve ICU utilization?

1. Yes

2. No, thank you


Contact Information

Robin Czajka, RNService Line Vice President, Cost Management, [email protected]

Cindy SalyerDirector, Premier Performance Partners, [email protected]

Jeffrey Wright, PhD, MDPhysician in Pulmonary and Critical Care, Baptist Memorial Health Care, Memphis, [email protected]

Maria Zhorne, PharmDCritical Care Clinical Pharmacy Specialist, Baptist Memorial Health Care, Memphis, [email protected]


References

1. Critical Care Statistics. (2018). Society of Critical Care Medicine. Retrieved fromhttp://www.sccm.org/Communications/Pages/CriticalCareStats.aspx

2. Barrett, M. L., Smith, M. W., Elixhauser, A., Honigman, L. S., Pines, J. M. (2014, December). Utilization of Intensive Care Services, 2011. HCUP Statistical Brief #185. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb185-Hospital-Intensive-Care-Units-2011.pdf

3. Gooch, R. A. Kahn, J. M. (February 2014). ICU bed supply, utilization and health care spending: an example of demand elasticity. JAMA, 311(6)

4. Czajka, Robin, Salyer, Cindy. (2017, December). Margin of Excellence: Intensive Care Unit (ICU) Utilization (White paper). Premier. Retrieved from http://offers.premierinc.com/20171208-CM-WC-ICU-Whitepaper_Landing-Page.html

5. Balas, Michele; Clemmer, Terry & Hargett, Ken. ICU Liberation: The Power of Pain Control, Minimal Sedation, and Early Mobility. ICU Liberation. 2015.

6. Jain, M., Miller, L., Belt, D., King, D., Berwick, D. M. (August 2006). Decline in ICU adverse events, nosocomial infections andcost through a quality improvement initiative focusing on teamwork and culture change. Quality and Safety in Health Care. 15(4)

7. Enos, Kate. (2017, December.) Premier Inc. Analysis Finds Opportunity to Reduce ICU Stays, Enhance Care Quality and Improve Patient Workflow. Premier. Retrieved from https://www.premierinc.com/premier-inc-analysis-finds-opportunity-reduce-icu-stays-enhance-care-quality-improve-patient-workflow/

8. QualityAdvisor™: Jan 2017-Dec. 2017 comparative data

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