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  

Cham

eleo

n  screen

 shot  

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

10

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50

60

70

80

90

100

Season

Ave

rage

LO

S H

ours

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

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30

40

50

60

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80

90

100

Season

aver

age

LOS

ho

urs

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  

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  

“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

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0

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100

Average

1

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  

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  

Management  of  Inpa(ent  Asthma    Impact on Asthma Readmission

Q1

2003

Q2

Q3

Q4

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2004

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2005

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2006

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2007

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2008

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2009

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2010

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2011

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2012

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2013

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2014

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0%

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30%

40%

50%

60%

Percent

Summary

1

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  

0%

5%

10%

15%

20%

25%

30%

35%

40%

Perc

enta

ge o

f Pai

tent

s w

ho R

etur

ned

WIth

in 1

80 D

ays

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  

0%

5%

10%

15%

20%

25%

30%

35%

40%

Perc

enta

ge o

f Inp

atie

nts

who

Ret

urne

d W

ithin

180

Day

s

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  

MOC  

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.

000.

250.

500.

751.

00

Prop

ortio

n

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  

ED

Direct Admit

DischargeHomeTransfer

Discharge Short Term

Facility

Discharge Long Term

Facility

PCP

Hospital Stay

Pa(ent  Flow  

ED

Direct Admit

DischargeHomeTransfer

Discharge Short Term

Facility

Discharge Long Term

Facility

PCP

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    

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

100  Sep-­‐12  

Oct-­‐12  

Nov-­‐12  

Dec-­‐12  

Jan-­‐13

 

Feb-­‐13  

Mar-­‐13  

Apr-­‐13  

May-­‐13  

Jun-­‐13

 

Jul-­‐1

3  

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  

ED

Direct Admit

DischargeHomeTransfer

Discharge Short Term

Facility

Discharge Long Term

Facility

PCP

Hospital Stay

Pa(ent  Flow  

ED

Direct Admit

DischargeHomeTransfer

Discharge Short Term

Facility

Discharge Long Term

Facility

PCPMedical Ward

ICU

Surgery Ward

OR

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

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40

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140

160

180

200

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