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New healthcare delivery models:
Interprofessional, regional, international Cheryl Hiddleson
MSN, RN, CCRN-E Director, Emory eICU Center
Timothy G. Buchman
PhD, MD, FACS, FCCP, MCCM Founding Director,
Emory Critical Care Center Emory eICU Center
10 Nov 2017
Disclosures: None
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Disclosure/Disclaimer
• Neither speaker has financial interests or other conflicts relevant to this talk – Dr. Buchman is Editor-in-Chief of Critical Care
Medicine and also serves as an advisor to the not-for-profit James S. McDonnell Foundation, a grantmaking philanthropy, www.jsmf.org
• All opinions are personal and do not represent those of Emory, SCCM, CMS, or Critical Care Medicine
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Talk Map
• Why eICU
• Outcomes based on recent research/Emory outcomes
• The International Experience • What has been learned • What remains uncertain • Where are we going….
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Georgia’s needs growing much faster than provider supply
Patient Population
The “Over 65’s” projected to increase
by 39% in the next 8 years
0.13 0.3 1.48
4.94
7.66 9.44
18-24 25-44 44-64 65-74 75-84 85+
CCM MDs needed /100,000 population:
Older Georgians require much
more CCM service
HRSA, 2006
Physician Demand
5.02%
10.71%
38.63%
-5.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
All GA
Growth Rate by Age Group 2017-2025
0-14
15-44
45-64
65+
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Physician Gap
AMA Masterfile
Angus, 2000
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Nursing Gap
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Here we are…
Up to 30% of inpatient hospital costs on <15% of the beds, lots of machines, but where are the clinicians?…
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Bring Expertise to the bedside
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The Emory Program: eRNs: 24 x 7 x 365 eMDs: nights weekends and holidays
Industry standard convergent eICU platform Multiple EMR, physiologic monitors
16 locations, 136 beds in 5 hospitals (2 university, 1 hybrid, 2 community)
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In Room Equipment
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Bidirectional Audio Visual Capability
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What we see: “Air Traffic Control for the ICU”
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Detecting state at the bedside: what needs to be done
• Physiologic time series
– Heart (EKG)
– Vasculature (Blood Pressure)
– Lungs (CO2)
– Brain (EEG)
– …
Beat-to-beat heart rate
heartnt heart
nt
1
time, sec
ECG II,
mV
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Data displays that mirror how we think about patients’ needs
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Situation Awareness Human Factors 37: 32-64 (1995)
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Detect
Track
Classify
Project
What we are (really) doing: Detection/Correction of Anomalies
Decide
Assign
Act
Evaluate
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Since go live May 2014
In the Clinical Operations Room: 92,852 eRN hours 19,656 eMD hours
On Camera
2,439 eMD Hours 3,702
eRN Hours
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Care Quality Improvements
• Decrease in severity-adjusted/actual mortality
• Decrease in severity-adjusted/actual LOS
• Increase in adherence to best practice for VTE
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Date of download: 4/17/2016 Copyright © 2016 American Medical
Association. All rights reserved.
From: Hospital Mortality, Length of Stay, and Preventable Complications Among Critically Ill Patients Before
and After Tele-ICU Reengineering of Critical Care Processes
JAMA. 2011;305(21):2175-2183. doi:10.1001/jama.2011.697
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Date of download: 4/17/2016 Copyright © 2016 American Medical
Association. All rights reserved.
From: Hospital Mortality, Length of Stay, and Preventable Complications Among Critically Ill Patients Before
and After Tele-ICU Reengineering of Critical Care Processes
JAMA. 2011;305(21):2175-2183. doi:10.1001/jama.2011.697
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Emory eICU Results: Community-Centered Hospital
eMDs
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Mo
rtal
ity
Rat
ios
Mortality Ratios (Actual over Predicted) of eICU Monitored Patients
ICU Mortality Ratio Hospital Mortality Ratio APACHE Predicted
eRNs
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Lives Saved
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Emory eICU Results: Community-Centered Hospital
eMDs
0.60
0.80
1.00
1.20
1.40
1.60
1.80
LOS
Rat
ios
LOS Ratios (Actual over Predicted) of eICU Monitored Patients
ICU LOS Ratio (All Pts) Hospital LOS Rate (All Pts)
ICU LOS Ratio (Excludes High Risk Stays) Hospital LOS Rate (Excludes High Risk Stays)
eRNs
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Resources Conserved
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Date of download: 4/17/2016 Copyright © 2016 American Medical
Association. All rights reserved.
From: Hospital Mortality, Length of Stay, and Preventable Complications Among Critically Ill Patients Before
and After Tele-ICU Reengineering of Critical Care Processes
JAMA. 2011;305(21):2175-2183. doi:10.1001/jama.2011.697
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VTE Best Practice Compliance
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
% of Patients on VTE Prophylaxis withing 24 hours of ICU Admit
Pts on VTE Prophy within 24 Hrs of ICU Admit-eSearch
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Emory total eICU
operational costs are
currently $643 per patient.
eICU staffing is based on patient ratios. This creates step fixed costs: if we monitored just 12 additional beds, our eICU costs per patient would
drop to approximately $500 (varies depending on occupancy rates).
$422+$155=$577 is break-even even if no ‘downstream’ cost savings
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Emory eICU analysis by Abt
Quantitative findings: Emory eICU compared to Nine other Hospitals • Decrease of roughly $1,486 in average Medicare spending per episode
(p<0.01) for a total of 4.6 million over the 15 month period
• Decrease in the rate of 60-day inpatient readmissions of 2.14% (p<0.10)
• Decrease in discharges to SNF and LTCHs of 6.9% (p<0.01) • Increase in discharges to home health of 4.9% • Declining trend in inpatient LOS for the two most recent quarters
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Turning Night into Day July-December 2016
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Key Elements of the Study/Trial
• Partner with a University health system in Australia. We chose Macquarie University
• Build a mini clinical operations room (COR) at the partner location
• Relocate Emory board certified intensivists and Emory critical care certified nurses to the partner site
• Have these team members cover the night shift during day time hours in Australia
• Operate simultaneously in the COR in Atlanta with eRNs and have an intensivist on call if needed
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Trail Making Test
• Validated neuropsychological test – visual attention – task switching
• Consists of two parts (A and B) in which the subject is instructed to connect a set of 25 dots as quickly as possible while still maintaining accuracy
• Test can provide information about visual search speed, scanning, speed of processing, mental flexibility, as well as executive functioning
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Timed tests
Form A Form B
Connect the dots in ascending numerical order… 1,2,3,4…25…
Connect the dots in ascending and strictly ALTERNATING numerical and alphabetical order… 1,A,2,B, 3, C…13
Errors not allowed must correct
as you go
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Subject Data 1: Nights, Jet Lag, Acclimatized to Days
Form A -Av Form B-Av B-A Av
Nights 14.25 19.9 5.65 Begin Shift
14.24 23.78 9.54 End Shift
Jet Lag 13.225 19.925 6.7 Begin Shift
14.26 20.46 6.2 End Shift
Days 12.325 17.825 5.5 Begin Shift
12.04 17.76 5.72 End Shift
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Early Outcome Data
Form A Typical completion times: 25-29 seconds • Emory completion times on average much faster • Fastest 12.04 end of 12 hours day time in Australia • Slowest 14.26 after 12 hours during jet lag Form B Typical completion times: 49-75 seconds • Emory completion times much faster • Fastest 17.76 end of 12 hours day time in Australia • Slowest 23.78 after 12 hours during night shift
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On the iPad – Self-Reported Fatigue
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Anecdotal Feedback
“Although I have been a long time night shift worker and believed I have successfully flipped back and forth from nights to days, I found that being on a consistent day schedule means I sleep pretty much the same number of hours every night and wake up before my alarm goes off everyday.” “The most significant aspect for me, was the change from working nights to working days. I felt like I had more time. When working nights, you can either sleep when your get home, or stay up all day and change to a day routine. Either way, your feel tired, and exhausted, especially working 3 or 4 12hour shifts in a row. In Australia, I completed my assigned shifts, went home and slept. The next morning I was able to accomplish whatever I had planned. I was not exhausted and did not lose a day just to make the transition from nights to days.”
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“Turning Night into Day”
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What has been learned
• In some circumstances, eICU consistently saves lives
• In some circumstances, eICU consistently saves costs
• In some circumstances, eICU enhances consistent practice
• eICU can support local teams when numbers and experience of bedside personnel are overwhelmed by complexity, acuity or volume
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What is not known
• Where impact of eICU is least/greatest
– Bedside coverage (physician, APP, nursing, AHP)
– Patient complexity (low, medium, high risk)
• Influence of local culture on eICU effectiveness
• Influence of eICU on local culture
• Influence of eICU on aggregate quality, safety, access, financial performance
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Next steps?