Reducing Patients Who Decompensate within 24 hours of Being Transferred to Floor from the EC

A Clinical Safety and Effectiveness Education Course Project by:Stephanie Mundy, M.D. and Kent Walters, MBA, CMPEThe University of Texas M. D. Anderson Cancer Center

October 15, 2009Reducing the Number of Admitted Patients Who Decompensate within 24 hours of Being Transferred to the Floor from the Emergency Center

Rationale Resource Utilization, Improve Patient Care2There is a need to improve how patient acuity is assessed in order to optimize our patient care resourcesTo improve patient care by reducing number of patients who decompensate and are transferred to ICU within 24 hours of admission to floor from the Emergency CenterDecompensate = patient had cardiopulmonary arrest or severe decline in physical status requiring emergent attention of the medical staffTo optimize utilization of nursing unit, telemetry, and ICU beds through improved assessment of patient acuity prior to transfer from the Emergency CenterBased on limited bed resources (physical space and staffing) for all units identified aboveRationale Problem Confirmation3During the period January 2006 through mid-November 2006 there were 94 patients who transferred from the floor to the ICU in less than 24 hours from admission from the Emergency Center or 1.45% of total admissions from the Emergency CenterAll patients transferred to the ICU were included, consisting of postoperative patients, patients transferred for a procedure or careful monitoring as well as those truly decompensatedRationale Research 4Nearly 85% of inpatients that had cardiac arrest showed identifiable signs of deterioration during the previous eight hours. Recognition of these signs and timely intervention may reduce morbidity and mortality.

Source: Bristow PJ, Hillman KM, Chey T, Daffurn K, Jacques TC, Norman SL, Bishop GF, Simmons EG: Rates of in-hospital arrests, deaths and intensive care admissions: The Effects of a Medical Emergency Team, MJA 2000;173:236-240.Background5The Emergency Center admits 35% of all hospital admissions at UTMDACC, which approximates 656 patients per monthEmergency Center patient acuity is significantly higher than a non-cancer specific emergency center:Facility% of Patients Admitted from EC% of Admissions to ICUUT M. D. Anderson Cancer Center35.0%7.0%Non-cancer Hospital13.9%1.3% (1)(1) Source: National Ambulatory Care Survey: 2003 Emergency Department Summary. Advance Data. Number 358. May 26, 2005. U.S. Department of Health and Human Services, CDC.Background6Project is first step in developing acute care scoring system for all patientsEC selected as pilot area given 35% of inpatient admissions originate from the EC; andEC inpatient admissions represent a higher acuity patient population with a greater chance of decompensating within 24 hours of being admitted to the floor.Aim Statement7Decrease by 25%, the decompensation rate (transfers to the ICU within 24h) for patients admitted to the floor from the Emergency Center, within 12 months. Aim StatementReducing the Number of Admitted Patients Who Decompensate within 24 hours of Being Transferred to the Floor from the EC

BusinessAdministrationQualityImprovementPharmacyNursingPhysicianClinicalInformaticsInformationSystemsMultidisciplinary Team Approach8Ishikawa Analysis9Ishikawa analyzed for commonality in process areas to determine an area of concern as viewed by all health care providers that contribute to patient decompensatingIshikawa processes were identified by physician, nursing, clerical, pharmacy, and business staff members through distribution of cause and effect diagram and focus groupsEach process then ranked (1 to 5, high to low) by each individual relative to chief concerns

Ishikawa (Fishbone) Diagram10

Ishikawa Analysis11Ishikawa Analysis12Sorted Histogram of Top Reasons for Patients Decompensating within 24 hours of Admission to Floor from the ECWhat We Uncovered13

Waste in how vital signs are documentedHandwritten on EC noteEntered into ClinicStationEntered into WhiteboardLikely need for improved ICU bed resource and utilizationImproved training needed on vital sign monitoringRoot cause analysis of why certain units have higher decompensation rate than othersPandora by John William Waterhouse, 189613Intervention Options14The cause and effect analysis resulted in intervention options:All patients reevaluated by MD prior to transferAll patients reevaluated by RN prior to transferComplex scoring system utilizing vital signs, comorbidities, type of cancer, labs etc. too time consumingClinicStation be modified to signal (red flashing) when vital signs trends are abnormal not feasible at current timeVital signs to be taken every 2 hours with split of CNA every 4 hours and RN every 4 hours and placed into ClinicStation creative staffing solution!Vital signs linked from bedside monitor to ClinicStation technically possible financially not

Selected Intervention15Criteria for selection was ease of implementation (people, process, and technology) relative to direct and indirect costsBased on criteria and testing of options it was discovered ClinicStation could print a vital sign trend in graph and table formatIntervention Implementation16

Current Process Mapping Intervention Implementation17

Intervention Implementation18

Intervention Implementation19Intervention implementation required using the Plan Do Check Act (PDCA) methodologyA process diagram was developed based on the perceived new work flow for reviewing vital sign trendsProcess flow charts posted in the EC and distributed to EC physicians, RNs, and CNAFollow-up written and verbal communication occurredSelected Intervention20

Table Format

Vital Sign Review in action2 keystrokes total review and print. Meets process and technology objectives.Graph FormatData Collection21Data was collected at 3 pointsInitial period of 11/17/06 to 11/30/06 and 12/1/06 to 12/31/06, and 01/1/06 to 04/30/09First data collection period saw no change in percent of patients who decompensateThough analysis determined sample too small to draw any conclusions as to effectiveness of interventionBaseline Data22BaselineVS EC PJan 06Feb 06Mar 06Apr 06May 06Jun 06Jul 06Aug 06Sep 06Oct 06NovA 06NovB 06# EC-Fl-ICU w/in 24 hr pts/ # EC adm pts01345UCL=3.18CL=2.30Percent of EC Admissions - 'EC-Floor-ICU within 24 Hours'11 month decompensation rate = 1.45%Data Collection 2nd Point23

Intervention 11/17/062.28% to 1.89% decompensation rateData Collection Comparison by Baseline, New EC, and EC Pod A24

New average of 0.7% for a 47.5% change since project inceptionIntervention Results25Solid improvement achieved during second data collection period compared to first data collection periodDuring the project period there was 33% compliance with the vital sign summary analysis, and only 33% of those patients transferred to the ICU during both periods had the vital sign data complete with indication of reviewImportant to note data was more inclusive than exclusive during first round of baseline data collectionObstacles Encountered26

Obstacles Encountered27Throughout the intervention process several obstacles encountered:Compliance with printing and signing vital sign trend graphHigh EC volume that contributed to reduced compliance on certain daysInconsistency in using ClinicStation for vital sign entryCompeting CS&E projects as well as other quality improvement initiatives information overload e.g. remembering what to do when and for whomObstacles - Communication28Obstacles Encountered Compliance Rate29Compliance PercentHow Obstacles Were Addressed30Communicate, Communicate, Communicate!Constant communication (direct and indirect) increased compliance rates significantlyCompliance rate improved when Dr. Mundy was working in the EC!

ROI Analysis Cost Basis31Average Cost per Day (H&C Only) and ALOS for Intensive Care UnitsJanuary 2008 - December 2008 Admissions

Medical ICU ALOS*5.91Medical ICU Avg Charge/Day$ 15,081 Medical ICU Avg Cost/Day$ 7,267

Pedi ICU ALOS*4.92Pedi ICU Avg Charge/Day$ 16,284 Pedi ICU Avg Cost/Day$ 7,877 Overall ICU Avg Cost Day$ 8,224

ROI Analysis Cost Avoidance32The project has significant impact on cost avoidance. Avoided costs included ICU charges not reimbursed due to payor (especially governmental).In a DRG environment, this is key and critical.The average ICU admission charge (bed, drugs, therapies, imaging) can average ~ $15,081 per day.The average ICU cost per day is $7,267.Reducing ICU bed days (especially in a DRG environment) by 47% results in an annual savings of ~$ 4,360,200.00 (600 ICU bed days avoided multiplied by $7,267).ROI Analysis Changes to Whiteboard and ClinicStation33Process of charting vitals directly into ClinicStation eliminates need for paper based progress notes. Productivity gains based on time involved in using paper based systems and then re-transcribing into ClinicStation.Other BenefitsImproved patient safety by reducing transposition errorsIncreased nursing time with patient instead of paperworkCompliance in entering vitals into ClinicStationDecrease in patient to physician time, andSignificant morale booster!Overall Conclusions34SustainabilityMonthly review of patient decompensating data to be presented by 3rd Thursday of month at EC Management meetingImprovements to be made include adding time reviewed with signature on medical record form (time stamp in ClinicStation now eliminates this step)Institutional LearningImproved understanding of how clinical processes should leverage technology to improve patient safety and maintain true patient centered care.

UT System and UT M. D. Anderson Cancer Center Executive Leadership for the opportunity35Pandoras BoxThank you!Patient admitted through EC who decompensates on floor & moved to ICU within 24 hours

Communication

Patient factors

ER / Enviornment

Methods

Staffing

Frequency of V / S in EC

Care Delayed -Consults do not come until primary MD sees pt.

EC team often desensitized to how sick the Pts may be

Admitting team challenge - transfer of care occurred even if pt still physically in EC

EC Record not always available to floor

Criteria for notification vital sign changes

Process to get in ICU

Delays in getting tests when busy

Vital signs questionable HR 130, Sys < 90

Neutropenic Fever

Sicker Pt results in higher % admitted

EC frequently busy

Contributing Factors

No Handoff to fellows who cover after clinic hours & on weekends?

Initiating Admission Orders in EC - process & timing varies

Waiting for ICU/tele/floor beds to be available

Priority to new EC Pt

EC MD write Admission orders for non-surgical pts

Requires > 40 % O2 to keep O2 sat. > 90%

Bilateral pneumonia

Patient & family satisfaction / dissatisfaction w/process

Variation of skill levels of Healthcare providers

Pts often not seen by Primary w/ in 24 hours

EC RN to patient ratio 1 - 4

RN cares for sickest first -Prioritize care for all patients

Limited # EC MDs

No consistent process/criteria for EC RN to report admitted pt changes to EC MD

RN -> RN handoffHow do they Prioritize?

No common language between care givers to communicate pt acuity

EC MD to EC MD report simply admitted no status report

EC MD to adm MD short, limited verbal handoff

Page operators unaware of updated call schedule

Floor RN difficulty which MD to call for orders

Primary attending full house + rounds clinic by 1300

Pager problems -Rolling over

Difficult no consistent path to communicate with Admitting team

Cancer Pts very complex + comorbidities

New EC patient vs Admitted EC patient needs

Admitted EC patient needs admitting orders

Admitted EC patient needs consultant but may not come until after primary team has visited

Delay in writing Admission orders when EC busy

One EC MD from 1:00 am to 9:30 am

ICU/sickest patients require more resources

Subtitle

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Company Name/Title

Type in the MR# of the pt you wish to take vital signs, hit enter

Logs into Clinic Station: ID, Password (if the CNA is registry, one of our USCs log them into C.S.)

Pt data screen opens. Scroll down to NSG DOCUMENTATION, click the mouse.

New screen opens w/ list of EC pts. Click on the name of pt again, in the new screen. This opens the C.S. vital sign sheet (SEE example page w/ #2 at the top)

Take the vital signs

Enter the information into the boxes Click save and complete.Click close (same screen)Screen returns to the list of EC pts.

Start New Patient

Manual ProcessMost take all of the patients vitals and write them on the old vital sign board, then enter the data into CS.

Process Variations

A few take the computer door to door and enter the data into CS immediately after the VS are taken. Moving from room to room w/ the computer is faster.

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Clinical Safety and Effectiveness ProjectReducing the Number of Admitted Patients Who Decompensate within 24 hours of Being Transferred to the Floor from the EC

ER Physician Check-out Process(patient is ready to leave EC)

Key Patient Status Indicators:1. Patient is DNR2. Patient is borderline or unstable3. Patient is neutropenic

EC PhysicianEC Physician prints out vital sign trend graph in Clinic Station and reviews trend.Place graph on top of chart.

EC PhysicianGraph is stamped by EC Physician using his/her own stamp

EC PhysicianEC Physician writes next to stamped signature:OK for Discharge,OK for Transfer to Floor, etc.

Nursing StaffRemoves vital sign trend graph (with MD stamp) and place it in box in Pod A or B

Component ProcessIf Patient is admitted but remains in EC greater than 2 hours post discharge i.e. waiting for bed

Patient is ready to be transferred from EC to room

Nursing StaffPrint out updated graph and review for abnormal trend

Stamp updated graph and write:OK for level of care or no significant changeStaple updated trend to EC physician trend graph in box on either POD A or B

No

Yes Abnormal Trend

Nursing Staff

1

Main process

Inform appropriate physician of trend

Physician and/or Nursing Staff document intervention results on trend graph

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8

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EC Physician Patient Checkout Process Flow Chart

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Clinical Safety and Effectiveness ProjectReducing number of patients who decompensate within 24 hours of admission to floor/unit

Routine patient vital signs recorded into ClinicStation every 2 hours

CNA record vital signs at:12a4a8a12p4p8p

Nursing Staff (RN) record vital signs at:2a6a10a2p6p10p

Abnormal vital sign(s) noted

CNA informs RN of abnormal vital sign(s)

RN rechecks vitals and checks trend chart

Abnormal vital sign(s) verified

RN notifies MD via Vocera

NO

Yes

YES

RN moves yellow flag to out position

MD receives Vocera and responds with confirmation ETA to evaluate patient

RN leaves room and continues normal work process