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A Value-Based Model for Reduction of Preventable Harm in Medical/Surgical Inpatients

A Value-Based Model for Reduction of Preventable Harm in Medical/Surgical Inpatients. Thanjavur S Ravikumar, Cordelia Sharma, et al. HIMSS ME-PI Community Meeting November 5, 2010.

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A Value-Based Model for Reduction of Preventable Harm in Medical/Surgical Inpatients

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  1. A Value-Based Model for Reduction of Preventable Harm in Medical/Surgical Inpatients Thanjavur S Ravikumar, Cordelia Sharma, et al. HIMSS ME-PI Community Meeting November 5, 2010 Geisinger Health System, Wilkes-Barre, PA; LIJ Medical Center, New Hyde Park, NY; Albert Einstein College of Medicine, Bronx, NY; Montefiore Medical Center, Bronx, NY;Feinstein Institute for Medical Research, Manhasset, NY

  2. Case #1 58 yr old man following colon resection proceeds to have a massive AMI – Cardiogenic Shock Issues: *Despite young age, patient had clinical evidence of cardiac disease - risk under estimation *Post op EKG shows changes, wrong evaluation by junior resident - cognitive dissonance - co-management vs. consultation *Junior resident Senior resident Attending hierarchy - power distance

  3. Case #2 55 yr old morbidly obese woman with sleep apnea undergoes bowel resection complicated by severe aspiration, pneumonia & respiratory arrest. • Issues: • * Failure to rescue • * Inter-team communication/care coordination • * Knowledge gap

  4. Case #3 88 yr old female undergoes radical surgery for pelvis tumor. On POD # 2 at 6:45 PM patient developed respiratory distress and decreased oxygen saturation. Surgical rapid response called. SICU attending as well as the surgical PA and residents respond. It is quickly determined that patient requires intubation. Pt is intubated by the intensivist while plans for transfer to SICU are made. Seemingly appropriate traditional mode of care. Is this sufficient?

  5. Effective Methods/Factors on Outcome • Multidisciplinary focus • Critical event training/simulation • Effective communication process • Physiologically based early warning systems and intervention

  6. Hypothesis & Objectives • Building safe hospital systems to improve value-based surgical outcomes is predicated on workflow redesign for dynamic risk stratification, coupled with “real time” mitigation of risk • Co-management model for hospitalized surgical cohort • Iterative process redesign adaptable to disparate systems • Outcome-based; cost-effective = value paradigm • Multidisciplinary teams, patient-centered • Applicability to medical/surgical adult inpatients

  7. Perioperative Deterioration: Outcome Depends on Patient Status Compensated Stability Physiologic Derangement Critical Event Decompensating Pseudo Stability - - - Lives Saved/QOL ― Disease Progression

  8. Acute Care System Redesign: 3 Zones vs. ROI ROI In Disease Progression Management Continuum of Care Rapid Response Code Team ROI / DISEASE PROGRESSION Zones of Intervention - - - Return on Investment ― Disease Progression

  9. Continuum of Care: Program Description and Domains R & D/Education Quality CER Preventable Harm Reduction Workflow Redesign Co-management of Hospitalized Patients Intensivist/Hospitalist with Medical/Surgical TeamsMultidisciplinary Rounds Acuity Stratified HAWK Rounds Real time communication Hospital Anatomy Redesign Hospitalist Led Floor-based Teams Aggregation of Patients Formation of safety net – PCU Enabling Technologies EHR Vocera Targeted Response Simulation Acuity Based Rounds (Hawk/Dove/ Risk Score) Complications Glossary Mortality Reduction SS 360 Scoring Financials Efficiency Unit Specific Costs Bed Mgmt Throughput ED, OR, ICU Impact DRG/Program Based Cost Discharge Planning; Transition of Care Total Cost Analysis

  10. Study Design and Methods Pilot SCoC Validation SCoC 1998 2001 A B C 2001 Medical Center Surgery 2005 TSI SPARCS Premier 2008 2004 PHAMIS Hospital-wide CoC Metrics & Analysis Dec 2008 Mortality, LOS, Cost, Readmission Multi-Hospital Database D Jun 2009 Linear Regression, Chi-Sq, t-Test, Fisher, Mann-Whitney U-Test Siemens CareScience QUEST Nov 2009

  11. Implementation Steps • Engagement of Stakeholders • Multidisciplinary Structure:- Floor based team building/cohorting- Restructure Hospitalist role/enhance ownership- One CoC MD – weekly rotation • Redesign Process Flow- Concurrent multidisciplinary CoC rounds in a.m.- CoC morning report- Hawk rounds, TOC, task assignment, TRT- Real time team and external communication- Creation of PCU • Tools- MDRT in Epic- Vocera build out- Mortality analysis, simulation- FCCS training- Protocols, care maps, algorithms

  12. A Day in the Continuum 00 23 1 7:30PM – 7:00AM Periodic Hawk Rounds (10PM, 2AM, 6AM) AM Discharge Prep 22 2 21 3 “Right Sequence” “Right Care” “Right Time” 20 4 “Right Rounding” “Right Team” “Right Handoffs” 7:00AM – 7:30AM Hospitalist Handoff Communication 7:00PM – 7:30PM Hospitalist Handoff Communication 19 5 Efficient Discharges -11:00AM Reduce holding – ED and PACU Real time Communication 6 18 7:30AM – 8:00AM Hospitalist Pre- Rounding on the Patient Floors 7 17 RRT & Code Calls Hawk Rounding Acuity Stratified Targeted Response 16 8 8:00AM – 9:00AM Simultaneous CoC Rounds 15 9 14 10 9:30AM – 7:00PM Hospitalist Patient Care & Continuum of Care Hawk Rounds 9:00AM – 9:30AM Hospitalist & Continuum of Care MD Hawk Huddle & Nursing Bed Huddle 13 11 12

  13. Rounding Tool Domains Patient History & Alerts Patient List Icon & HAWK List Provider Nursing PT / OT Pharmacy Nutrition & Care Management

  14. Pilot SCoC: Mortality

  15. Pilot SCoC

  16. Pilot SCoC: Outcome Summary

  17. Validation SCoC

  18. Validation SCoC * * Mortality Odds Ratio Index: LIJMC vs. LIJMC - Surgery 2005 vs. 2007 1.2 1.6 Significant at 95% confidence level

  19. Validation SCoC: LOS

  20. Validation SCoC: Readmissions

  21. Hospital-wide CoC: Mortality

  22. Hospital-wide CoC: Mortality Source: CareScience Quality Manager

  23. Cost Savings Pilot SCoC • Cost saved from decreased LOS in PCU • $851,511 - $2,007,388 Validation SCoC • ALOS and direct costs by CMS surgical DRG

  24. Summary • Hospital Care Delivery Redesign: • Real time acuity stratification and mitigation of risk • Applicability to disparate hospital systems / patient populations • Cost saving outweighs resource requirement • Limitations: • Not an RCT • Administrative data reliance • SMR: Constant risk fallacy “Differential measurement error” “Inconsistent proxy measures of risk”

  25. Acute Care System Redesign Patient Safety Strategies Continuum of Care Rapid Response Code Team ROI / DISEASE PROGRESSION Bend the Curve Shift to the Left Zones of Intervention - - - Return on Investment ― Disease Progression

  26. Future Initiatives • FCCS course for hospitalists/mid level providers/nurses at GWV • Education using simulation of real case scenarios • Floor based data on outcomes • Readmission analysis • Predictive modeling - Mortality analysis - Implementation of SS360 score - Development of risk stratification score for medical pts - Bio markers • DRG based protocols/algorithms

  27. Proven Care® Continuum of Care

  28. Patient Safety in Flight

  29. Case #1 58 yr old man with known CAD/HTN/DM/smoker undergoes elective colon resection WHAT HAPPENED WHAT CONTINUUM OF CARE COULD DO 12 PM – Pt comes out of OR 1 AM – Intern evaluates pt for chest pain. Orders EKG and labs: notifies senior resident that there are no new EKG changes - pt’s pain resolves. 4 AM – Nurse calls intern for ↑ HR intern orders beta-blocker and HR ↓ 7 AM – Chief resident notes during rounds that earlier EKG had significant changes that intern missed. Cardiology consult called STAT. 8 AM – Cardiologist diagnoses massive MI. Pt becomes hypotensive 9 AM – Pt moved to ICU – deteriorates and expires from cardiac arrest. 12 PM – Pt identified as “HAWK” by risk stratification thru review of OR pts with surgical team 2 AM – Pt seen during Hawk rounds. Intern and CoC review EKG and identify new changes. Surgical chief resident and Attg called. Cardiology consulted.Cardiologist evaluates pt.Pt taken to cath lab emergently.Survives

  30. Case #2 45 yr old morbidly obese woman develops emesis after bowel resection: Resp Ther places pt on BIPAP at night without knowledge of emesis. Pt aspirates massively due to positive pressure and expires: Knowledge gap Lack of inter team communication Solution: CoC develops simulation based scenario to demonstrate contraindication of BIPAP and incorporates in the curriculum of all stake holders

  31. Case #3 WHAT HAPPENED WHAT CONTINUUM OF CARE COULD DO POD #1 – 2 AM – Confusion fever 9 AM – O2Sat 79% 2L 02 11 AM – Weaned to RA 1 PM – Labored respirations confusion 02Sat 83%--02 Restarted 5 AM – Multiple episodes of confusion – psych consulted POD #1 9 AM –Primary team calls Continuum of Care team - Attending/PA Pt evaluated diagnostic and Tx recommendations made and Pt triaged to appropriate setting.Hawk rounding avoids RRT call and reintubation POD #2 3 PM – Labored respirations, CXR bilateral effusions 8 PM – Pt found unresponsive in chair. RRT called. Pt intubated, TX to SICU Continuum of Care F/U after transfer from ICU or PCU to floor and available to surgical team. POD #7 D/C to Rehab/home POD # 5 – Extubated POD # 7 – Transfer to floor POD # 7 & 8 –Continuum of Care f/u POD # 9 – D/C to Rehab

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