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