informacs+atthe+bedside+ datais+the+key+to+improvement · 4/2/2015 ·...

Informa(cs at the Bedside Data is the key to Improvement

Chris Maloney MD PhD Professor, Department of Pediatrics

Adjunct Professor, Department of Biomedical Informa(cs Associate Chief Medical Officer, Primary Children’s Hospital

Disclosure: Dr. Maloney has licensed eAsthma Tracker soFware to Symptom.ly He has received no royal(es to date

Outline

1. Informa(cs at Primary Children’s Hospital 2. Management of inpa(ent bronchioli(s 3. Management of inpa(ent asthma 4. Management of ambulatory asthma 5. Managing flow from the ED to inpa(ent 6. Managing flow from the ICU to inpa(ent

Informa(cs at Primary Children’s Hospital HELP in 1990: Health Evalua(on through Logical Processing

Hierarchical database with computerized decision support Homer Warner, Al Pryor, Reed Gardner, Sco[ Evans Ptext Applica(on Language required to develop reports

HELP2 in 2000: Graphical User Interface with rela(onal database

Computerized Decision support via ForeSite object oriented rules engine Paul Clayton, Stan Huff, Sco[ Narus, Beatrice Rocha Clinical Data Repository – CDR Electronic Data Warehouse – EDW Java and JavaScript language for executable code Rela(onal database è easy report genera(on

Chameleon (formerly known as Pa(ent Tracker) 2003 Local command and control with computerized decision support Doug Wolfe, Joe Hales, Fred Farr, Kent Ward, Chris Maloney Java and JavaScript language for executable code Requires access to HELP2 ADT (Admission, Discharge, Transfer) table

Informa(cs at Primary Children’s Hospital

n screen

Outline

1. Informa(cs at Primary Children’s Hospital 2.  Management of inpa/ent bronchioli/s 3. Management of inpa(ent asthma 4. Management of ambulatory asthma 5. Managing flow from the ED to inpa(ent 6. Managing flow from the ICU to inpa(ent

Management of inpa(ent bronchioli(s

¨  Lower airway infec(on caused by variety of viruses v  Respiratory Syncy(al Virus (RSV) is most common

¨  Most common diagnosis effec(ng children < 2 years ¨  Fills up hospital beds across the country during winter ¨  No vaccine available

¨  Care is completely suppor(ve ¨  Very low mortality

Germ Watch

Management of inpa(ent bronchioli(s

¨  Q: When is pa(ent discharged on home oxygen? A: When we need the bed.

¨  Varia(on increases costs ¨  Standardiza(on improves outcomes ¨  Value = quality/cost

¨  The hospital is our laboratory

Management of Inpa(ent Bronchioli(s ¨  Ins(tuted admit order set ¨  Developed adequately explicit discharge criteria ¨  Standardized inpa(ent care for:

¤  Nutri(on ¤  Suc(oning ¤  Bronchodilator use ¤  Oxygen therapy

¨  Educated nursing staff ¨  Educated physicians ¨  Educated respiratory therapy staff ¨  Rolled out winter season 2004-‐2005 ¨  Had measurement systems in place

Management of Inpa(ent Bronchioli(s

you MANAGE

what you

MEASURE

97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-100

Season

SOURCE: EDW CaseMix & Transactions

Average Length of Stay Hours, PCMC Bronchiolitis AdmissionsSOI 1 & 2, exclusions applied

69.4509

64.7369

59.4523

59.0430

56.2649

59.6503

59.0641

67.4385

76.5625

76.0589

69.8915

67.8807

63.4732

AverageCases

CPM implemented on IMSU for part of 2004-‐2005 season

CPM fully implemented for 2005-‐2006 season

LOS was the shortest it has been since the CPM was implemented

A Disrup've Innova'on

was needed

Observa(on Unit Home Oxygen Therapy (OU-‐HOT)

Inclusion Criteria 3-‐24 months No bacterial infec(on Family willing and able to manage home oxygen Reliable transporta(on Has primary care provider Lives within 30 minutes of health care facility

Exclusion Other medical condi(ons affec(ng current illness Possible asthma Observed or history of apnea

Observa(on Unit Home Oxygen Therapy (OU-‐HOT)

•  Wean oxygen to discharge threshold – <12 months: < 0.5 liters per minute – >12 months: <0.8 liters per minute

•  Minimize interven(on –  ie. suc(oning

•  Discharge aFer 8 hours of stability

OU-‐HOT 2010-‐11

•  309 pa(ents admi[ed to OU-‐HOT –  72% discharged in less than 24 hours –  60% discharged on oxygen –  Average length of stay 17 hours –  23% admi[ed to inpa(ent status

97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 10-110

Season

includes RivertonPediatric unit

SOURCE: EDW CaseMix & Transactions

Average Length of Stay Hours, PCMC Bronchiolitis AdmissionsSOI 1 or 2, exclusions applied

69.40509

64.66369

59.43523

59.04430

56.18649

59.58503

59.02641

67.45385

76.48625

75.94588

69.85911

67.57804

63.27725

48.62837

AverageCases

Average LOS 48.6 hours

Global mean: 60.8 hrs Global mean: 66.1 hrs

Outline

1. Informa(cs at Primary Children’s Hospital 2. Management of inpa(ent bronchioli(s 3.  Management of inpa/ent asthma 4. Management of ambulatory asthma 5. Managing flow from the ED to inpa(ent 6. Managing flow from the ICU to inpa(ent

Ø Characterized by ①  Variable and Recurring Symptoms ②  Airflow Obstruc(on ③  Bronchial Hyper-‐responsiveness ④  Underlying Inflamma(on

Asthma Working Defini(on

•  Most common pediatric chronic illness (prevalence: 13.8%)

•  7.1 million children < 18 years of age had asthma (2009)

•  High health care use and costs ($20.7 billion/year in total costs)

–  640,000 ED and 456,000 hospital visits in children < 18 (2007)

–  Readmission rates: 10-30% at 6 months to 20-50% at 12 months

•  Suboptimal chronic asthma control in the ambulatory setting

Pediatric Asthma: Epidemiology

Asthma: Epidemiology 1.  Asthma is the most common chronic illness in children,

with a life(me prevalence of 14% and a significant impact on health care use and costs

2.  Readmission rates are high, ranging from about 10-‐30% within 6 months and 20-‐50% within 12 months of hospital discharge

3.  Children who are hospitalized for asthma are at increased risk for subsequent admissions.

4.  Significant gap between asthma evidence and actual care provided to children

5.  Preven(ng readmissions in children hospitalized with asthma can reduce health care costs related to asthma

Management of Inpa(ent Asthma

Medical Management

Readmission Preven(on

Acute Severity Assessment

Chronic Severity Assessment

Use of Short Ac(ng Beta Agonist

Adequate Preven(ve Treatment

Appropriate Delivery of Albuterol Asthma Educa(on

Appropriate Use of Atrovent Wri[en Ac(on Plan

Use of Systemic Cor(costeroids

Follow-‐up Care Arrangement

Oral Systemic Cor(costeroids vs. IV On-‐Going

Monitoring

Inpa(ent Interven(ons

Measure % compliance

Inpatient specific care measures

1. Documented asthma acute severity assessment at the time of admission 38%

2. Use of Quick Relievers 98%

3. Use of systemic corticosteroid for all patients 100%

4. Use of oral (not IV) systemic corticosteroids 56%

5. Use of Ipratropium Bromide restricted to < 24 hrs after admission 24%

6. Use of albuterol delivered by MDI (not nebulized) 23%

Re-exacerbation/readmission prevention measures

7. Documented chronic asthma severity assessment 19%

8. Parental participation in an asthma education class 39%

9. Written asthma action plan 5%

10. Scheduled follow-up appointment with the PCP at discharge 22%

Asthma Quality Measures: PCH 2005 * Nkoy et al. Pediatrics 2008

PCH Compliance Post-‐CPM

Medical Management

Monitoring

“Making it

Easy to do it Right”

Brent C. James, MD Mstat N Engl J Med. 2001 Sep 27;345(13):965-‐70

Asthma CDS Facilitates Pediatric Core Measure Compliance

Management of Inpa(ent Asthma Impact on Asthma Length of Stay

Average

86 75 52 68 69 50 58 58 82 69 52 95 65 58 74 88 92 71 49 94 113 91 85 81 157 141 130 89 139 94 80 79 136 112 89 90 139 95 130 157 130 120 76 107 90 106 155 130n

Medical Management

Monitoring

Management of Inpa(ent Asthma Impact on Asthma Readmission

Percent

Summary

86 75 52 68 69 50 58 58 82 69 52 95 65 58 74 88 92 71 49 94 113 91 85 81 157 141 130 89 139 94 80 79 136 112 89 90 139 95 130 157 130 120 76 107 90 106 155 130n

Asthma Readmissions: PCH vs. Freestanding Children’s Hospitals

2008 Asthma Inpatient Encounter (APR-DRG 141) Returns to Hospital within 180 Days – Same APR-DRG

% Inpatient Returns % ED Returns % Observation Returns

PCH vs. Other Children’s Hospitals

2010 Asthma Inpatient Encounter (APR-DRG 141) Returns to Hospital within 180 Days – Same APR-DRG

% Inpatient Returns % ED Returns % Observation Returns

Outline

1. Informa(cs at Primary Children’s Hospital 2. Management of inpa(ent bronchioli(s 3. Management of inpa(ent asthma 4.  Management of ambulatory asthma 5. Managing flow from the ED to inpa(ent 6. Managing flow from the ICU to inpa(ent

TAKING CHARGE OF YOUR ASTHMA

Mobile Web Version

SAMPLE WORK AND INFORMATION FLOW OF THE e-‐ASTHMA TRACKER

Incen(ve

QUALITY MEASURES

ASTHMA SYMPTOM QUESTIONNAIRE

ADDITIONAL CLINICAL INFORMATION

Report and Decision Support Page

Information for patient AND provider

Asthma control over time

RECOMMENDATIONS & TAKING ACTION

Your weekly Asthma Control Test scores higher than 19 are in the green zone.

Follow the recommenda(ons of your asthma care according to your score.

Clinic Interface – SHARING ACCOUNTABILITY

SCORE REVIEW

Review pa(ent’s responses to the Asthma Control Test (ACT) by clicking on the score. Any comments the pa(ent included will also show.

FLAGGED PATIENTS

A list of pa(ents with “Unresolved Issue” checked under comments will show in the “Flagged Pa3ents” page. Once “Unresolved Issue” is unchecked under comments, the pa(ent will no longer be listed on this page.

New Pa[erns (Intermi[ent Asthma)

Stepping up to reach good control

New Patterns (Persistent Asthma)

“The cat”

“I ran out of my controller”

Asthma Readmissions: users vs. non users 0.

0 100 200 300 400

No Days since Hospital Discharge

Non Users Users

Time to First (ED/hospital) Readmission (adjusted for age and race)

Outline

1. Informa(cs at Primary Children’s Hospital 2. Management of inpa(ent bronchioli(s 3. Management of inpa(ent asthma 4. Management of ambulatory asthma 5.  Managing flow from the ED to inpa/ent 6. Managing flow from the ICU to inpa(ent

Pa(ent Flow

Direct Admit

DischargeHomeTransfer

Discharge Short Term

Facility

Discharge Long Term

Facility

Hospital Stay

Pa(ent Flow

Direct Admit

Facility

Discharge Long Term

Facility

Hospital Stay

Movement from ED to Floor

•  ED leadership upset with pa(ent flow •  ED leadership claims floor is barrier o  Pa(ent is ready, but floor is not o  Need an admission nurse

•  Developed measurements systems •  Shared the results

Dr. Paul Batalldan

“Every system is perfectly created

to achieve the results it gets”

Movement from ED to Floor Request to nurse supervisor response

Response to bed available

Bed available to floor arrival

Rogers, Mister

Lincoln, Abraham

Stanley

you MANAGE

what you

MEASURE

100 Sep-‐12

Oct-‐12

Nov-‐12

Dec-‐12

Jan-‐13

Feb-‐13

Mar-‐13

Apr-‐13

May-‐13

Jun-‐13

Jul-‐1

Aug-‐13

Available to Comple/on

Assigned to Available

Request to Assigned

Minutes

Measuring The Process

Be[er to remain silent

and be thought a fool than to speak

and remove all doubt

Minutes

Measuring The Process

Outline

1. Informa(cs at Primary Children’s Hospital 2. Management of inpa(ent bronchioli(s 3. Management of inpa(ent asthma 4. Management of ambulatory asthma 5. Managing flow from the ED to inpa(ent 6.  Managing flow from the ICU to inpa/ent

Direct Admit

Facility

Discharge Long Term

Facility

Hospital Stay

Pa(ent Flow

Direct Admit

Facility

Discharge Long Term

Facility

PCPMedical Ward

Surgery Ward

Pa(ent Flow

Rogers, Mister

Lincoln, Abe

Lincoln, Abraham Gen

Movement from PICU to Floor Request to nurse supervisor response

Response to bed available

Bed available to floor arrival

Goal is < 180 minutes

Median

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Time to Transfer Patient from PICU to Floor Time (hrs)

Outline

1. Informa(cs at Primary Children’s Hospital 2. Management of inpa(ent bronchioli(s 3. Management of inpa(ent asthma 4. Management of ambulatory asthma 5. Managing flow from the ED to inpa(ent 6. Managing flow from the ICU to inpa(ent

Thank You

informacs+atthe+bedside+ datais+the+key+to+improvement · 4/2/2015 ·...

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