Redesign the System: Improving ICU Efficiencies and Patient FlowBela Patel, MD
Regional CMO - Memorial Hermann Hospital Texas Medical Center
Vice Dean of Healthcare Quality
Division Director of Critical Care Medicine
The University of Texas Health Science Center – Houston
This presenter has
nothing to disclose.
ICU Breakout 1 – Session 2
November 2, 2016
Could we improve care and flow?
Emergency Center
Wards
WardHome
Other facility
Stabilization ComplicationsEnd-of-
Life
MICU
Reduce admission
delays
Family meetings
VAP & BSI prevention
Weaning protocol
RRT teamSepsis
protocol
Weaning
ED to ICU Admits – baseline data
<4 hours >4 hours
Patients 345 314
% of total patients 52% 48%
Mortalty Rate 14% 17%
Hospital LOS 9.10 10.30
CMI 2.33 2.60
Age 55 58
% Male 52% 48%
% Female 48% 52%
30 day readmits 40 32
30 day readmits-- Same DRG 12 7
Care Complete to Depart for MICU
Mortality 18% higher
Length of stay 11% higher
ED to MICU Transfers
Results Before After
Transfer < 4 hours 53% 74%
Hospital LOS 9.1 days 7.8 days
Streamline Communication
AfterBefore
100: MICU Projects Completed
Supply room relocation and organization
Calmoseptine pre-stocked in pyxis
Infection Control Compliance (Supply
Caddies Installed)
Care Team Identification
Ventilator weaning protocol
Turning schedule and compliance
New MICU orientation for physician
residents
Maintaining Plateau Pressures
HUC workflow sheet
Employee Lockers
Biohazard trash cans available on unit
Visitor Badge System
Visitor Packet- Spanish Translation
Supply system/Stocking Patient
Rooms
Locked Medication Cabinets
Body Mechanics for Opening Doors
(Door handles)
Line Documentation Sheet
Mediscus Pad use on all patients
RRT Communication Tool
Charge Nurse Book
Nurse Driven Foley Removal Protocol
Bedside Shift Report
ER Float Guide
Sepsis Interventions
Education
Interdepartmental Team Building with champions
Screening and “countdown” check lists
Standardized streamlined ordersets
Limited Antibiotic choices
Daily audits with rapid feedback to the EC
Addressed workflow by decreasing time to
Transfer
Blood Transfusions
Central line placement
Utilized RRT (when available) to assist in resuscitation in ED.
Patient Demographics
Time Intervals
Lactates
MAP
Apical HR
Vasopressors
Intropes
Fluids
Sepsis Flag
Sepsis
Dashboard
Sepsis Dashboard – Patient Level
Key time intervals in relation to MICU arrival for one patient
Sepsis Patients – Time to AntibioticsED to MICU Patients Monthly Summary – October 2015
9
13/14 (93%) of patients received 1st
antibiotics within 3 hours of ED Arrival
10
Sepsis Patients
– Fluids
ResuscitationED to MICU Patients Monthly
Summary
• 4/12 (17%) of patients received 2 L fluids within 3 hours of ED arrival
• 12/14 (92%) received ANY fluids within 6 hours of ED arrival
• $1200 cost per case reduction in direct costs
Sepsis Outcomes: LOS, Cost, Mortality
Mortality Reduction
Illness Risk 1- Mild 2- Moderate 3-Major 4- Extreme
% Decrease Same 19% 26% Same
Rapid Response Team
• Early recognition
• Rounding on high risk
patients-ICU transfers
• Alerting system implemented
• Early sepsis intervention
Floor codes decreased by 50% to <1.5 per 1000 patent days
Saving 2-4 ICU days per avoided code
Medicine ICU Hospital Flow
Decreased Mortality 18%
Decreased LOS 32%
Increased Admissions
Increased Capacity
Improved Hospital Flow
“Created 4 beds”
Physician Quality and Safety Academy
