update in medicine and primary care november 20, 2015 · pre-tcc implementation post-tcc...

Update in Medicine and Primary Care November 20, 2015

Bill Beninati Medical Director for Intermountain

Life Flight and Telecritical Care

Disclosures

No financial conflicts to disclose

Bottom Line

Telecritical care:

- Saves lives

- Prevents complications

- Saves money for the hospital and the insurer – without cutting staff at the bedside

- The attending at the bedside is the attending – we are consultants

Overview

- Why TeleCritical Care (TCC)

- Intermountain TCC Program

- Intermountain TCC Process

- TCC Outcomes

- Way Ahead

Critical Care in 2015

High cost environment

• Nationally – 5% of inpatient volume/20-40% of hospital costs

• Projected demand is rising due to aging population

High risk environment

• Patients are unstable

• Care is complex – potentially dangerous therapies, fluid care plans, multiple team members

Can any of us promise a patient entering our ICU that no harm will come to them from their care? Terry Clemmer, MD

Nursing Surveillance & Problem Identification

Physician Contact

Communicate Information

Intervention

Intervention Assessment

Many Points of Failure & Delay

National Context

Does this really work?

6 ICUs in 5 hospitals • University of Texas Health Science Center at Houston

• VISICU (now Phillips eICU)

Patients • 2034 patients preintervention

• 2108 patients postintervention

“Local physicians delegated full treatment authority to the tele-ICU for 655 patients (31.1%)”

Thomas JAMA 2009

Thomas JAMA 2009

Telecritical Care Experience - Houston

Tele-ICU Outcomes

Identified 3,133 studies/reviewed 176/included 13

All used before-after design

Significant heterogeneity in studies

Definition of Tele-ICU

Severity of illness adjustment

Vendor affiliation of authors

Bottom line

Significantly improved – ICU mortality and length of stay

Not significantly improved – Hospital mortality and length of stay

Young Arch Intern Med 2011

ICU Mortality

Young Arch Intern Med 2011

Hospital Mortality

Young Arch Intern Med 2011

ICU Length of Stay

Young Arch Intern Med 2011

Hospital Length of Stay

Young Arch Intern Med 2011

Lilly et al JAMA 2011

7 ICUs from single academic medical center

Pre-/post analysis with 6290 patients

Phillips eICU system

Pre/Post analysis of 118,990 adult 56 ICUs in 32 hospitals from 19 US health care systems -All regions of US represented -Hospital size ranged 88-834 beds -Rural, suburban, and urban populations -Many types of ICUs (med/surg, medical, surgical, CCU, neuro, cardiothoracic) -Nonteaching, unaffiliated teaching, academic

Lilly Chest 2014

ICU and Hospital Mortality Decreased

ICU and Hospital LOS Decreased

Factors accounting for the improvements in mortality and LOS

• Intensivist case review within 1 hour of ICU admission

• More frequent review and use of performance data

• Higher levels of adherence to ICU best practices

• More rapid responses to alerts and alarms

• More frequent interdisciplinary rounds

• More effective ICU committee as judged by ICU clinical leaders

Multicenter Study

Not associated with outcome:

• 24/7 intensivist coverage – outcomes still improved

• Open or closed ICUs – both benefitted

• Disorganized and incomplete documentation at bedside – associated with no improvement

• Allowing opt out pathways – associated with no improvement

• Specific structural strategies for support center organization and operations

Lilly Chest 2013

Intermountain Program

Tele-Critical Care Medicine – What’s in a name?

- Name captures:

- Remote process

- Focused on critical care regardless of location

- Potential to engage pre-ICU patients such as rapid response, Code Blue outside ICU, early sepsis

- High-reliability Critical Care

- Tele-CCM is not an attempt to overturn the way we practice critical care at Intermountain hospitals

- Tool to further extend high-reliability care

Intermountain Care Process

- Intensive Medicine Clinical Program

- Critical Care Development Team

- Guidelines

- Protocols

- Order sets

Decision support built into orders - Antibiotic selection

Decision support built into orders - Lung protective ventilation

Decision support built into orders - Electrolyte replacement

Decision support built into orders - Common medications

Decision support built into orders - Shock management

What is TCC?

A remote monitoring and support center where an intensivist physician and critical care nurses observe real-time clinical data remotely and assist patients and providers in our hospitals via interactive technology.

Bunker A strong building that is mostly below ground and that is used to keep soldiers, weapons, etc., safe from attacks (Merriam-Webster)

Medical housing area bunker – Balad Air Base, Iraq

Command Center – A facility from which a commander and his or her representatives direct operations and control forces (The Free Dictionary)

Air Operations Center – Undisclosed location in Southwest Asia

Support Center A remote facility that uses experienced staff and electronic tools to support the care provided at the bedside (Bill Beninati)

TCCM Support Center – Disclosed location in Midvale, Utah

Referral Hospitals

(24/7 intensivist coverage)

IMED

McKay-Dee

LDSH

Utah Valley

Dixie

Community Hospitals

(have an ICU but no intensivists)

Cassia (no TCC MD)

Logan

Park City

Riverton

Alta View

American Fork

Cedar City

Rural/Critical Access Hospitals (no ICU)

Star Valley, Afton, WY

Sevier Valley-Pending

Star Valley – Afton, WY

TeleCritical

Care Support Center

HELP/HELP2 iCentra

Skype for Business

Bedside Monitor Feed

Phone from bedside

Life Flight/ Transfer Center

Best-practice Rounding Sheets

Physician Notes/ Orders

Reactive Support (meds/watch/Co

de Blue)

Transfer Decision

Bedside Monitor Feed

Situational Awareness – Informatics-developed Tool

*Uncertain future in iCentra

TCC Nurse Scope Proactive patient rounding – on all patients

Best practice – facilitated compliance : • DVT (Deep Vein Thrombosis) Prophylaxis

• Sepsis Bundle

• VAP (Ventilator Acquired Pneumonia) Prevention

• Stress ulcer prophylaxis

• RASS (Richmond Agitation Sedation Scale) & CAM (Confusion Assessment Method) sedation scale documentation

Reactive clinical support •Assist bedside – med check, transfusions, watch patient

Nurse Rounding Sheet

TCC Physician Scope

Automatic consult on patients with no critical care attending at bedside • Within 1 hour of admission

• Daily follow-up

Support TCC nurses with clinical decision making as they do their rounds

Assist in immediate response to patient instability when the bedside physician is delayed

ICU Cases since TCC Implementation

31%

24%

17%

10%

4%

4%

3%

2% 2% 1%

1% 1%

IMEDUtah ValleyMcKay-DeeDixieLDSHLoganAmerican ForkCedar CityAVHCassiaRivertonPark City

ICU Cases since TCC Implementation

85%

15%

TertiaryCommunity

TCC Physician – Heavy engagement

TCC Physician – Minimal engagement

TCC Physician Scope

Structured rounding on high-acuity patients • Second set of eyes

Support Transfer Center to facilitate rapid and seamless transfer of ICU patients from outside, and within, Intermountain • No change in natural referral patterns

Support Life Flight, including Rural Ground Transport, as medical control physicians.

TCC Physicians – help us help you First call to triage nighttime calls?

• BP/HR out of range, decreased urine output

• Abnormal results on AM labs

• Etcetera

No order from TCC without a note • Better documentation than your cross cover?

New admission – help with orders while attending dictates H&P – after agreeing on plan

Anything else?

Additional Scope

Manage important ICU culture change

- Minimize sedation/Maximize mobility

Critical Care Ultrasound

- Support bedside team using point of care US to increase reliability of care

Intermountain TCC Outcomes

9.9

38.1

23.3

13.1

7.5

4.22.3

1.1 0.4

9.7

37.7

23.2

13.6

7.8

4.32.2

1.1 0.4010

2030

40

0 0-56-10

11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50 0 0-5

6-1011-1

516-2

021-2

526-3

031-3

536-4

041-4

546-5

0

Pre-TCC Implementation Post-TCC Implementation

Prop

ortio

n of

Pat

ient

s (%

)

Acute Physiology ScoresGraphs by Pre- vs. Post-TCC Implementation

For Tertiary HospitalsProportional Distribution of Patient Acuities

No effect on Acuity in Referral Hospitals

P=0.17

Significant Shift to Higher Acuity in Community Hospitals

16.5

43.2

23.1

10.1

4.21.3 0.9 0.4 0.2

13.0

45.6

23.4

12.1

3.71.6 0.4 0.30

50

0 0-5 6-10

11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50 0 0-5 6-1

011

-1516

-2021

-2526

-3031

-3536

-4041

-4546

-50

Pre-TCC Implementation Post-TCC Implementation

Pro

porti

on o

f Pat

ient

s (%

)

Acute Physiology ScoresGraphs by Pre- vs. Post-TCC Implementation

For Community Hospitals (excl. Cassia)Proportional Distribution of Patient Acuities

P=0.002

Disposition from Community Hospitals – We seem to be decreasing transfers

Pre-TCC Post-TCC

Home + Home Health 2,331 69.0% 1,876 69.1%

Transfer to SNF, Rehab 425 12.6% 385 14.2%

Hospice 72 2.1% 54 2.0%

Transfer to Acute Care Hospital 295 8.7% 215 7.9%

Transfer to Psych 105 3.1% 87 3.2%

Left AMA 16 0.5% 19 0.7%

Other 34 1.0% 29 1.1%

Expired 99 2.9% 50 1.8%

3,377 2,715

42% Relative risk reduction

40% Relative risk reduction

Financial Analysis

- Analysis performed 1 year after implementation - 6 months after full implementation

- Compared Pre- and Post-TCC cost models

Annualized Estimates Community Tertiary

Estimated Savings $1,014,476 $3,354,364

Estimated Payment Impact ($888,833) ($2,459,017)

Estimated NOI Impact $125,643 $895,347

Overall NOI Impact $1.02 Million

Outcomes Analysis to Date - TCC is helping community hospitals keep

more/sicker patients - and manage them with significantly less chance of

mortality

- A strong signal is emerging that we are able to reduce costs

- We have not clarified the mechanism of the benefit - Analysis is ongoing

Where do we go from here?

Outreach – rural Intermountain hospitals System-wide RRT protocols/orders

- assistance applying this in small hospitals with limited staff

ED patients who would benefit from stabilization pre-transport

Medical control for Life Flight and Rural Ground Transport

Requires MOU and privileging at all hospitals

Outreach – Non-Intermountain hospitals We have implemented with Star Valley (Afton, WY)

Multiple additional hospitals in pipeline

Major questions/challenges

working in multiple EMR’s

do Intermountain clinical programs translate outside system?

Proposed Physician Support Center: Goal Through a single contact, physicians – within and outside the Intermountain system – can:

• Transfer a patient – if best option for patient, family, physician

• Receive referral assistance

• Connect with a specialist for a patient consult

• Gain access to (a growing list of) Intermountain TeleHealth Services

• Transport a patient

• Connect with a specialist for remote patient management

Integrating Existing Services:

Life Flight

TeleHealth Management

TeleHealth Consultation

Intermountain Transfer Center

Physician calls Transfer Center for Intermountain support

Concept in development

Life Flight

TeleHealth Management

TeleHealth Consultation

Critical Care/Stroke Infectious Disease/Peds Trauma

Intermountain Transfer Center

Transfer Center has access to the TeleHealth clinicians

Integrating Existing Services:

Concept in development

Life Flight

TeleHealth Management

TeleHealth Consultation

Intermountain Transfer Center

TeleHealth consultation may escalate to TeleHealth Critical Care staff using telehealth video enabled equipment for distant management of patient

Integrating Existing Services:

Concept in development

Life Flight

TeleHealth Management

TeleHealth Consultation

Intermountain Transfer Center

Transport of patient to a higher-acuity facility is provided when the patient cannot be adequately treated in the local environment:

• Established protocols and communication flows ensure seamless Intermountain care process across continuum

Integrating Existing Services:

Concept in development

• Improve the Intermountain Transfer Center process by giving the Center immediate access to clinical expertise

• Life Flight patients backed up by full resources of Intermountain

• Versus non-aligned air transport alternatives

• Intermountain TeleHealth Services backed up by full resources of Intermountain

• Versus geographically distant telemedicine providers

• Allow Intermountain to function as a system • Provide a single access gateway for additional (otherwise

disconnected) services as they’re developed

Physician Support Center Benefits:

Concept in development

DISCUSSION

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