Bela Patel MD
Associate Professor of Medicine
UT Health Science Center Houston
Memorial Hermann Hospital – Texas Medical Center
 Khalid
Almoosa MD
 Lillian Kao MD
 Pratik Doshi MD
 Brandy McKelvy MD
 Ruth Siska RN, Tammy Campos RN
 Kathy Luther RN, Kathy Masters
 Jeffrey Katz MD, Eric Thomas MD
 Divisions of Critical Care, Pulmonary and
Sleep Medicine
 MHH nurses, respiratory therapy, pharmacy
1050 Bed Level 1 Trauma Center
65,000 Emergency Department visits per
year
▪ 37% admitted to hospital
▪ 10% ICU Admissions plus Transfers
 150 ICU Beds
 16 MICU Beds
 1200 admissions/year
 > 95% capacity
MICU
 Decrease
MICU length of stay by 25%
through reduction in complication rates
and improvement in compliance with
evidenced based practices over 36
months to improve flow and capacity.
Emergency
Center
ICU
Re duce
a dmission
de lays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Se psis
protocol
Weaning
protocol
VAP & BSI
prevention
Fa mily
me e tings
Ward
Home
Other facility
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Eme rgency
Ce nte r
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wa rds
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Wa rd
Home
Othe r fa cility
Eme rgency
Ce nter
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wa rds
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Wa rd
Home
Othe r fa cility
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
We aning
Complications
End-ofLi fe
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Eme rgency
Ce nte r
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wa rds
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Wa rd
Home
Othe r fa cility
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Admission Delays to the ICU
Delayed ICU transfer (>4 hours from care
complete to ICU arrival)
▪ Increased hospital mortality
▪ Increased hospital LOS
▪ Increased ICU LOS
Chalfin et al. Impact of delayed transfer of critically ill patients from the emergency
department to the intensive care unit. Crit care med 2007; 35: 1477-83.
Care Complete to Depart MICU Admits
<4 hours
>4 hours
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
Patients
Mortality
18% higher
Length of stay
11% higher
EC
Transfer
ICU
Patients to MICU
Care Complete to depart <4 hours
74%
53%
Before
After
Patients to MICU
Arrival to Depart <4 hours
10
9,1
7,8
Hospital LOS in days
8
6
Ряд1
4
2
0
Before
After
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
Floor Codes per 1000 patient days
3,0
Floor Codes per 1000 pt Days
2,5
2,52
1,91
2,0
1,66
1,5
1,0
0,5
0,0
FY 08 Pre
FY09 Transition
FY10 Post
 RRT
protocols and structure have spread
to 9 hospitals in the system
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
1.
2.
3.
4.
5.
Serum lactate measured
Blood cultures prior to antibiotic
administration
Broad-spectrum antibiotics administered

Within 3 hours of ED arrival or 1 hour non-ED admission


Initial minimum of 20 mL/kg of crystalloid
Vasopressors to keep MAP > 65 mm Hg


Maintain central venous pressure > 8 mm Hg
Central venous O2 saturation (Scvo2) > 70%
Treat hypotension with fluids +/vasopressors
Persistent hypotension
Lactate
Blood Cultures
Antibiotics
Fluids/Vaso
CVP >8
ScVO2
авг.09
июл.09
июн.09
май.09
апр.09
мар.09
фев.09
янв.09
дек.08
ноя.08
окт.08
сен.08
авг.08
июл.08
июн.08
май.08
апр.08
мар.08
фев.08
янв.08
дек.07
ноя.07
окт.07
сен.07
авг.07
июл.07
июн.07
май.07
апр.07
мар.07
фев.07
янв.07
дек.06
ноя.06
окт.06
сен.06
авг.06
Compliance with Bundle Elements
100
90
80
70
60
50
40
30
20
10
0
Sepsis -Illness Risk 4- Mortality Rate Reduction
Jan-04
EGDT - began Jan-07
1.0
UCL=0.887
Proportion
0.8
0.6
_
P=0.398
0.4
0.2
0.0
LCL=0
1
8
15
22
29
36
Sample
Tests performed with unequal sample sizes
43
50
57
64
Mortality Rates
APR-DRG 720 Septicemia
49%
40%
Before
After
14%
10%
Illness Risk 4
Illness Risk 3
EDs
MICU
ICUs
11
Hospital
ICUs
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
 Expansion
into multiple ICUs next month
followed by global implementation for
the 11 hospital system
MICU
TSICU
NTICU
11 hospitals
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
VAP Bundle Compliance - Jan06-Jul09
100
Percent compliance
95
90
85
80
75
70
Variable
HO B
Sxn
Oral C are
Peptic Ulcer Disease Px
Sedation Holiday
DVT PX
65
Q1-06 Q 2-06 Q 3-06 Q4-06 Q1-07 Q2-07 Q3-07 Q 4-07 Q 1-08 Q 2-08 Q3-08 Q4-08 Q2-09 Q 2-09
 TSICU
Zero VAPS for 28 months
 CCU Zero VAPS for 18 months
 72% Reduction of VAPS across 7 ICUs
 Expanded Bundle Elements to 12
hospitals
MICU CVC-Related BSI Infection Rate per 1000 Risk Days
Zero BSI since Nov 09
UL3
Rate
Avg
10
9
8
7
6
5
4
3
2
1
0
LL3
6
ICUs
 7 Hospitals
 76% Reduction in Central Line Infections
Infection
Increased LOS Added cost
Pneumonia 6
$57,000
Bacteremia 7
$63,000
Wound
7
$3,100
UTI
1
$700
Emergency
Center
ICU
Reduce
admission
delays
Stabilization
Weaning
Complications
End-ofLife
Wards
RRT team
Sepsis
protocol
Weaning
protocol
VAP & BSI
prevention
Family
meetings
Ward
Home
Other facility
No timeline
“1 more
day”
Delays in
family
conferences
High risk of
death
Patient
admitted to the
MICU
No process
for
organizing
conferences
Treatment
No structure
to
conferences
Inconsistency
among MDs
Family
conference
Palliative
care
Not
multidisciplinary;
no attending
Ethics
Delays in
palliative
care
Patient
admitted to the
MICU
High risk-ofdeath patients
identified
Decisions
Nurse
manager
Family
conference
Future
meetings
Documentation
Schedule family
conference
Team members
notified
Nurse
manager or
Social
worker
Baseline 10.1 days
Mortality Rate -MICU Patients
Mortality Rate -- Medicine
Patients
19,0%
19,2%
5,34%
Baseline
Intervention
Baseline
Length of Stay MICU deaths Medicare Only
9,39
5,04%
Intervention
Length of Stay MICU Deaths >2
days
14,3
12,2
6,04
Baseline
Intervention
Baseline
Intervention
Mean LOS in MICU
UCL = 5.16
MEAN = 4.02
LCL = 2.96
Admissions to MICU
160
140
UCL = 150.18
120
100
80
60
40
20
0
MEAN = 104.6
LCL = 59.1
110
Occupancy Rate in MICU
100
UCL = 96.48
90
80
MEAN = 85.5
70
LCL = 74.68
60
Mortality Rate in MICU
30%
25%
UCL = 20.89%
20%
MEAN = 12.07%
15%
10%
5%
0%
LCL = 3.43%
Through improved quality of care and
safe practices, these changes collectively
resulted in an overall savings of $5.1
million per year in decreased length of
stay
 Additional revenue from increased
admissions

25
Days
20
15
10
5
0
 Thank
you