UMass Memorial Welcomes
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1 UMass Memorial Welcomes National Conference of State Legislatures May 6, 2011 Craig M. Lilly, M.D. Professor of Medicine, Anesthesiology, and Surgery University of Massachusetts Medical School United States of America a community working together to conquer diseases
2 UMass Memorial Health Care An integrated health care system supporting over 1 million members of the central Massachusetts community 1,600 physicians 3,500 registered nurses 13,500 support personnel In 2010 we served 58,762 inpatients, 254,162 patients visited our emergency departments and over 1 million outpatients visited our providers
3 Critical Care Need No one plans to be critically ill today The number of Americans over 64 years of age is rapidly increasing 1,2 and uses more critical care services Utilization 1. Angus et al 2000 JAMA 284: HRSA report to congress
4 The UMass Memorial System Approach to Meeting the Needs of Our Patients We needed to be more efficient We needed to provide the care that we would want for our loved ones 24 hours a day We needed to support our community hospital partners to deliver more care locally We used tele-medicine tools to transform the way we delivered critical care
5 Approach to telemedicine Bedside ICU and eicu Collaboration Lead to Improved Outcomes New pathways for communication and sharing best practice 24/7 access to an intensivist at the touch of a button Patented ICU alerts and proactive identification of patients who can benefit eicu supporting excellent bedside providers
6 We performed a tele-icu study We targeted ICU best practices and costly complications We measured mortality and cost of care before and after we implemented the tele ICU We compared the outcomes of concurrent cases managed with and without the tele-icu
7 Tele-ICU associated process changes Pre-intervention Group Processes Bedside Monitor alarms ICU daily goal sheet Telephonic case review Initiated by house staff or affiliate practitioner Tele-ICU Group Processes Physiological Trend alerts Abnormal lab value alerts Review of response to alerts Off-site team rounding Electronic detection of non adherence Real time auditing Nurse Manager audits Tele-ICU team audits Tele-ICU workstation review Initiated by Tele-ICU intensivist Includes: Electronic medical record Imaging studies Interactive audio and video of patient Interaction with nurse and respiratory therapist Assessment of response to therapy
8 Rates of Adherence to Best Practice Guidelines Increased Significantly Clinical Practice Guideline Adherence Pre-intervention Group Percent (n/eligible) Tele-ICU Group Percent (n/eligible) P value Stress Ulcer Prophylaxis 83 (1253/1505) 96 (4550/4760) < DVT Prophylaxis 85 (1299/1527) 99.5 (4707/4733) < Acute Coronary Syndrome 80 (311/391) 99 (2866/2894) < Ventilator Associated Pneumonia Prevention 33 (190/582) 52 (770/1492) < 0.001
9 Rates of Complications Complication Pre-intervention Group Percent (n/eligible) Tele-ICU Group Percent (n/eligible) P value Ventilator associated pneumonia 5 (76/1529) 0.7 (32/4761) < CRBSI* 1 (19/1529) 0.6 (29/4761) 0.01 Acute Kidney Injury 12 (174/1453) 12 (540/4565) 0.88 *Catheter related blood stream infection
10
11 Tele-ICU Associated Volume Increase Annualized we were able to care for 478 incremental cases with little change in our labor costs
12 Tele-ICU Associated Cost Savings The cost savings were in excess of $5, (2005 USD) per case
13 Financial Impact to Medical Center We cared for 11% more ICU cases a year while reducing the cost per case by more than $5,000 This change in financial performance was substantially larger than the $3.15M annual operating costs of the eicu program The capital cost of $7.1 M was recovered in less than 1 year
14 Multi Center Tele-ICU Intervention Study Study termination 118,990 admissions to 60 ICUs of 35 hospitals ranging from 80 to 798 beds in size from 18 health care systems located in 15 states
15 Outcomes Hospital Mortality (10.8 vs. 9.9; p = 0.003) Hospital length of stay ( vs ; p < 0.001)
16 ACCP Tele-ICU Survey Top and bottom quintile of improvement comparison Characteristics of Top performing ICUs: They adhere to critical care best practices Short response to alerts and alarms for physiological Instability There was multi disciplinary collaboration Before the tele-icu they had critical care Surveys from 111 hospitals from 22 states and 37 health care systems were completed
17 Leadership Council Clinical Support Services Nutrition, Pharmacy, Respiratory Therapy, Care Coordination, Clinical Quality Critical Care Operations Committee Medical Center President Hospitalists Tele-ICU Nurse Manager Medical Director Nurse Manager Medical Director Nurse Manager Medical Director Nurse Manager Medical Director Nurse Manager Medical Director NICU PICU Cardiac ICUs Medical ICUs Surgical ICUs Neuro ICU Nurse Manager Medical Director Nurse Manager Medical Director Emergency Departments* * For critical care functions Post Anesthesia Care Units * McCauley K, Irwin RS. Chest 2006; 130:
18 Community Hospital Tele-ICU Program Objectives 1. The primary aim of the program was to increase the volume of higher acuity community hospital ICU cases without increasing mortality or length of stay 2. To review the effects of the program on community hospital ICU case volume, acuity, operational efficiency, and mortality 3. To review how the program affected hospital and payer cost
19 Reengineering Critical Care Effects on Community Hospital ICU Volume
20 Average APACHE Scores Number of Cases Who are these patients? MS - DRG Post Count Pre Count MS - DRG Post APACHE Pre APACHE 871 Septicemia or severe sepsis w/o MV 96+ hours w MCC 189 Pulmonary edema & respiratory failure 637 Diabetes w MCC 922 Other injury, poisoning & toxic effect diag w MCC 177 Respiratory infections & inflammations w MCC 208 Respiratory system diagnosis w ventilator support <96 hours 207 Respiratory system diagnosis w ventilator support 96+ hours 291 Heart failure & shock w MCC 917 Poisoning & toxic effects of drugs w MCC 377 G.I. hemorrhage w MCC
21 Effects on Best Practice Adherence Community Hospital 1 Best Practice Pre-intervention group (n=397) Tele-ICU group (n=569) P value Beta Blocker Administration 123/148 (83%) 77/88 (88%) 0.5 DVT Prevention 273/391 (70%) 372/437 (85%) < Stress Ulcer Prevention Community Hospital 2 264/377(70%) 359/412 (87%) < Best Practice Pre-intervention group (n=530) Tele-ICU group (n=808) P value Beta Blocker Administration 54/63 (85%) 68/77 (88%) 0.84 DVT Prevention 473/521 (91%) 749/759 (99%) < Stress Ulcer Prevention 481/515 (93%) 688/705 (97%) < VAP Prevention 84/108 (78%) 212/239 (89%) < 0.001
22 Mortality 1. Mortality for all cases presenting to these community hospitals was lower with tele-icu support than before but this difference was not statistically significant Hospital mortality of admitted and transferred patients Hospital 1 Pre-intervention group (n=469) Tele-ICU group (n=584) Total Mortality (n,%) 38 (8.1) 40 (6.8) -19% 0.5 Hospital mortality of admitted and transferred patients Hospital 2 Pre-intervention group (n=872) Tele-ICU group (n=924) Total Mortality (n,%) 101 (11.6) 100 (10.8) -7.4% 0.8
23 Improving Hospital Adjusted LOS for ICU Cases Hospital LOS (adjusted) Pre Post Pre Post Hospital 1 Hospital 2 Hospital 1 Pre Hospital 1 Post Hospital 2 Pre Hospital 2 Post
24 Propensity Matched Cost Study cases managed at an academic medical center or a community hospital were matched on age, admission diagnosis, APACHE IV score 2. Costs were compared using an activity based cost accounting system and audited by an external accounting firm 3. Community hospital cases were managed at lower hospital costs than academic medical center cases (10,000 USD per case) 225 cases/community hospital X $10,000/case = $2.25M Potential Payor Savings
25 A New Model for the Regional Delivery of Critical Care Academic Medical Center Preferential transport of high acuity cases Preferential transport of lower acuity cases Community Hospital
26 Summary How are telemedicine tools being used? Electronic support helps make us more efficient Tele-ICU is part of a safer care environment More patients can get quality care near their homes The cost of ICU care across the region is lower
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