Medical Critical Care 2013 Year End Review

Medical Critical Care Year End Review

FY 2013

The Division of Medical Critical Care is excited to share a review of its achievements for FY13. We are proud of the continued attainment of excellent clinical outcomes, strong performance to improve the safety of our patients, and ability to implement innovative programs that meet best practice standards. This work has been led by the Medical Intensivists of Christiana Care Pulmonary Associates in conjunction with a strong partnership with the nursing staff of the MICU and WICU. Additionally, our success would not be possible without the dedicated care provided by the Critical Care Physician Assistants, Respiratory Therapists, Rehab services, and other ancillary support. As a result of our collective efforts we have demonstrated improved mortality in our critically ill patients, which are amongst the most severely ill in the entire nation. Additionally, we have made substantial improvements in ventilator duration, device utilization, and hospital acquired infection rates. The Medical intensivists have expanded their scope to bring expert critical care in areas outside of the MICU and WICU, resulting in improved outcomes for our patients in the CICU and during emergent situations such as RRT and code blue. We are leaders in demonstrating the value of multidisciplinary collaboration with rounds and daily checklists, as well as integrating Patient and Family Centered principles into the care delivery of our patients.

Vinay Maheshwari, MD, FCCP Director, Medical Critical Care

Medical Critical Care Year End Review

The patients in the MICU and WICU are amongst the most severely ill within the entire VISICU national database*. We have consistently demonstrated outstanding outcomes in relation to severity adjusted mortality and ICU length of stay and rank amongst the top decile of all programs within the VISICU database.

CCHS had the 4th lowest Hospital Mortality ratio compared to the other health systems in the national database

CCHS had the 2nd lowest ICU LOS Ratio in compared to the other health systems in the national database

*based on APACHE IV

Medical Critical Care Year End Review

MICU Apache Data

12

0.68

% of Deaths

10 8

0.66

Q2 2012 448 476 67.05

Q3 2012 419 439 67.76

MICU Mortality 0.52

0.45

0.66

0.42

0.53

6 4 2 0

Q4 2012 Q1 2013 Q2 2013 471 486 476 505 526 503 69.24 68.64 68.04

0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Quarter

Actual Deaths (%) O:E Mortality Ratio Mortality Ratio

MICU APACHE Data * Source VISICU Quarter Q4 2011 Q1 2012 Number of Patients 416 474 Number of Unit Stays 439 517 Average APACHE Score 68.92 70.73

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

0.81 0.91

0.82

0.91

0.77

Actual LOS 1

0.83

0.8 0.75 0.6 0.4 0.2 0

Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Quarter

Medical Critical Care Year End Review

O:E ICU LOS Ratio

LOS Ratio

Days

MICU LOS

The MICU Actual Deaths % has improved by 44% from Q4 2011 to Q2 2013

WICU Apache Data WICU APACHE Data * Source VISICU Q4 2011 Q1 2012 Number of Patients 140 150 Number of Unit Stays 147 159 Average APACHE Score 69.23 63.92

Q2 2012 164 168 63.93

Q3 2012 150 154 62.55

Q4 2012 151 156 63.94

0.69

0.59 0.5

0.47 0.32

0.8 0.6

0.37

0.4 0.2

Mortality Ratio

# of Deaths

O:E Mortality Ratio

1 0.87

Q2 2013 161 173 64.52

Actual Deaths (%)

WICU Mortality 14 12 10 8 6 4 2 0

Q1 2013 171 181 63.51

The WICU Actual Deaths % has improved by 44% from Q4 2011 to Q2 2013

0 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Quarter

WICU LOS

Days

3 2

0.86

0.92

0.78

1

0.87

O:E ICU LOS Ratio

0.8 0.72

0.78

0.71

0.6 0.4

1

0.2

0

0 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Quarter

*Mortality and LOS Ratios- are Actual days/Predicted days

Medical Critical Care Year End Review

LOS Ratio

4

Actual LOS

MV LOS Reduction Although there has been a 9% increase inpatient volume since FY2011, patient ventilator days have been reduced by ½ a day and that has been associated with a reduction of Hospital LOS by almost a full day.

14

14.9

13.96

1021 13.13

12 977

Days

10

1000

960 6.54

6

6.51

5.98

940

4

920

2

900

0

880

Fiscal Year

FY11

Number of Patients

FY12 Hospital LOS

MICU

1020

980

935

8

1040

# of Patients

16

FY13 Ventilator Days

Patient totals are based on hospital admission date by fiscal year.

298 13.08

12

Days

295 10.64

10

10.92

283

8

4.59

4

290 285 280

273

6

4.48

275 3.76

2

270

265

0 Fiscal Year

260 FY11

Number of Patients

WICU

300

FY12 Hospital LOS

Medical Critical Care Year End Review

FY13 Ventilator Time Days

# of Patients

14

MICU Off Shift Extubation Process Improved Off shift extubations in MICU from baseline of 23% to 44% MV reduction from 5.3days to 4.7days ICU LOS reduction from 6.0days to 5.2days

Sepsis Value Improvement Team Created a multidisciplinary team aimed at improving the outcomes related to Sepsis Approved by CCHS as 5th DRG population based VIT in April 2013 Dashboard created to follow clinical results starting July 2013 Demonstration of significant improvement in multiple areas

Improved Performance by a full Letter grade on Sepsis VIT Scorecard

Medical Critical Care Year End Review

2013*- Reflects first 8 months of 2013

Reduction in Harm

CAUTI -MICU 21 14 6

5 0 2010

2011

2012

15 10

1000

5

500 2

0 2010

2013 * Device Days

2012

# of Infections

3

Device Days

# of Infections

6000 5000 4000 3000 2000 1000 0

7

2011

8

2 0 2010

2011

Device Days

2012

Year

0 2013*

0

CY Year Device Days

Infections

VAP-WICU 5000 4000 3000 2000 1000 0

Probable VAP

The MICU has consistently had a 25% reduction in VAPs since 2010 with 0 infections in the first 6 months of 2013*

# of Probable VAPs

2010

0 2013*

2011

0 2012

The WICU has had 0 CLABSI infections since 2011

Device Days

# of Probable VAPs

6

500

2

VAP-MICU 5

1500 1000

Device Days

The MICU had a 30% reduction in CLABSI infections from 2010 to 2012 with only 3 CLABSI infections in 9 months of 2013*

8

Infections

4

Infections

10 8 6 4 2 0

2013 *

7

6

2013 *

CY Year

2012

CLABSI-WICU

10

2010

2011

0

The WICU has demonstrated a nearly 90% reduction in CAUTI infections since 2010

CLABSI-MICU 6

1

Device Days

69% reduction in MICU CAUTI infections from 2010 to 2012 with the trend continuing in 2013

12 10 8 6 4 2 0

2

CY Year

Infections

CY Year

1500

Device Days

10

2000 17

6 4

1500

5

1000

2

2

1

0 2010

2011

2012

500 0 2013*

0

Device Days

15

20

Device Days

7000 6000 5000 4000 3000 2000 1000 0

# of Infections

20

23

Device Days

# of Infections

25

CAUTI-WICU

Year Device Days

Probable VAP

The WICU has demonstrated significant reductions in Probable with the trend continuing in 2013*

RRT Utilization

Medical Critical Care Year End Review

RRT Utilization Multiple RRT Calls

10

7

2 within 12 hours

3 within 48 hours

Linear (2 within 12 hours)

Linear (3 within 48 hours) 11

7

6

5

5

4

3 13-Jan

6

13-Feb

Mar 13

2

3

13-Apr

13-May

5

3

1

3

13-Jun

13-Jul

4 13-Aug

1 13-Sep

Non-ICU Codes/RRT Calls per 1000 Discharges CCHS RRT calls per 1000 disch 1.9

2.4 2.7

2.3

2.8

3.3

3.2

Total Non-ICU codes per 1000 disch 2.9

2.4

2.8

2.7

3.8

1.6

2.2

3.5

3.2

41.3 38.6 37.3 33.0 35.5 37.2 50.5 46.6 44.1 41.3 37.7 34.9 38.4 32.5 40.3 32.0

Reduction in RRT utilization over first 6 months of 2013 Non- ICU code rate has improved or remained unchanged Improvement in number of RRT’s within first 24 hours of admission Reduced number of multiple RRT’s

Medical Critical Care Year End Review

Daily Checklist MICU and WICU collaborated to create uniform ICU best practice checklist and integration on multidisciplinary rounds. Being utilized > 95% of all patients on daily basis in both units.

This checklist was shared across the system and now integrated into the rounds of each adult ICU at CCHS.

Collaboration with Christiana Care Cardiology Consultants (C4) Dedicated Intensivist to CICU 1/1/2012 Established agreement with C4 for co-management with medical critical care (CCPA) of critically ill patients admitted to Cardiology service to CICU. Started 7/1/2012 Implemented Daily Checklist to CICU Rounds Helped establish multidisciplinary rounds in CICU Significant reductions in device days and Hospital Acquired Infections have been achieved during this timeframe.

CICU ECARE Data ICU LOS Ratio

Vent. Days Ratio

Linear (Vent. Days Ratio)

1.21 0.91

Q1 2012

0.83 0.79

Q2 2012

0.75 0.72

Q3 2012

0.74 0.74

0.88 0.83

Q4 2012

Q1 2013

Medical Critical Care Year End Review

0.73 0.68

Q2 2013

CRTI Initiative Baseline (2011) 9.10

MICU Alert Intervention (Jan. 10th –August 2013 ) 7.17

% Reduction

MICULOS Avg. (Days)

3.79

3.25

14%

Hosp.LOS Avg. (Days)

10.66

8.60

19%

EDLOS Avg. (Hrs.)

21%

MICU data from Donna Mahoney, Director, Data Acquisition & Measurement

Baseline (July 2011-March 2012) 8.24

MAT Intervention (April 2012-Sept. 2013) 6.42

% Reduction

MICULOS Avg.(Days)

3.16

2.70

15%

Hosp.LOS Avg. (Days)

7.79

7.45

5%

EDLOS Avg. (Hrs.)

22%

WICU data from Donna Mahoney, Director, Data Acquisition & Measurement

The Medical Critical Care Division has adopted the Choosing Wisely campaign and its principles of physician stewardship, or the ideal that physicians are held responsible for providing effective healthcare, and therefore should be at the center of driving cost control. We have created initiatives to address each of the following recommendations endorsed by the Society of Critical Care Medicine.

Don't order diagnostic tests at regular intervals (e.g., daily), but rather in response to specific clinical questions.

Don't transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL. Don't use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.

Don't deeply sedate mechanically ventilated patients without specific indications, and do attempt to lighten sedation daily.

Don't continue life support for patients at high risk for death or impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

Do not initiate or continue antimicrobial agents without specifying an evidence-based duration or endpoint and reassessing daily whether to narrow the spectrum of coverage based on cultures and clinical response.

Do not place or maintain arterial and central venous catheters in critically ill patients without specific indications.

Medical Critical Care Year End Review

Early Mobility

This was a multidisciplinary initiative designed to focus on the functional mobility of patients immediately upon ICU admission. This process included identifying appropriate patients on a daily basis, developing efficient workflows between various providers, and a paradigm shift in culture. As a result, there was a substantial increase in the number of patients who received Rehab services and this was associated with improved outcomes as highlighted below.

Data Category Number of Patient Stays Patents that received PT Services Percentage of patients that received PT Services Average MICU LOS (d) Average total hospital LOS (d) Average mechanical ventilator LOS (d)

Baseline (CY 2011)

Intervention Period (FY2013)

1688 274

1691 620

16.2%

36.7%

4.3 12.37 5.4

2.7 11.2 4.3

MICU LOS has been reduced by 1.6 days compared to baseline period CY2011

Roaming ICU Provider Has allowed more immediate evaluation of critically ill patients in non-MICU locations. This has resulted in improved RRT outcomes and utilization, as well as improved collaborative efforts in the Cardiac ICU. Both are elucidated further in improved clinical outcomes.

Medical Critical Care Year End Review

2010 Rising Star Award- Vinay Maheshwari 2010 Specialist of the Year- Michael Benninghoff 2010 ANCC Magnet Award 2011 Internal Medicine Teacher of the Year- Badrish Patel 2012 Kimberly Clark HAI Watchdog Award- 1st Place- Wilmington ICU 2013 Internal Medicine Teacher of the Year- Mithil Gajera 2013-8 Nursing Excellence Nominees and 3 award winners 2012-2015 AACN Beacon Award -Silver CNS Nurse of the Year from Delaware Today- Maureen Seckel SDS Learning Institute Center for Simulation Award- Bridget Remel Unit Based Value Improvement Team (UBVIT) Recognition Award- Wilmington ICU

Medical Critical Care Year End Review