EDUCATION,TIME AND
OUTCOMES
AECOM COGME
November 6, 2006
Vladimir Kvetan,MD
Critical Care Medicine
Critical Care Medicine
Montefiore Medical Center
CLINICAL SERVICES
CRITICALCARE
ADULTCLINICALSERVICES
MOSESDIVISION
M
EDICALICU
10LEVEL1
SURGICALICU
6LEVEL
M
ULTI-DISCIPLINARY
CRITICALCARECONSULT/
SURGICALCRITICALCAREUNIT RESPIRATORYTHERAPY
24LEVEL1
NEUROSURGERYICU CARDIO-THORACICICU
6LEVEL1
12LEVEL1
W
EILERDIVISION
M
EDICAL/SURGICALICU
14LEVEL1
CARDIO-THORACIC
ICU/CCU
18LEVEL1
CRITICALCAERCONSULTAND
RESPIRATORYTHERAPY
Mortality
Risk Adjusted Mortality Index
Mechanical
Ventilation
Group
-7.1%
Primary
Procedure
Group
-26.1%
Admission
Diagnosis
Group
0.00
-11.8%
0.20
U.S. Peer Group (CCM - F)
0.40
0.60
Index
0.80
1.00
1.20
Benchmark Hospitals (includes MMC)
Adapted from 100 Top Hospitals, Solucient, LLC.
Comparison of National Health
Initiatives
P a tie n t S a fe ty In itia tive s Im p a c t o n A vo id a b le D e a th s
7 0 ,0 0 0
6 0 ,0 0 0
IO M M id -R a n g e o f D e a th s
d u e to M e d ic a l E rro rs
5 0 ,0 0 0
4 0 ,0 0 0
3 0 ,0 0 0
2 0 ,0 0 0
1 0 ,0 0 0
0
ACPOE
E B R H ig h -ris k N IC U
E v id e n c e B a s e d
R e fe rra ls
CPOE
Bar coded M eds
Ed Larsen in HIMSS
Standards Insight
March 2003
In te n s iv is t S ta ffin g
EDUCATION, TIME &
OUTCOMES
•
•
•
•
•
•
•
Hours of the day
Day of the week
Month of the year
Year in training
Time of teaching
Clarity of goals
Volume of cases
JULY vs JANUARY
• Finkelman JD: Mortality and length of stay of
patients admitted to the ICU in July
Crit Care Med 2004, 32(5):1161
- 29,084 ICU patients
- Risk adjusted July ICU admissions did not have
higher hospital mortality rates
WEEKDAY vs WEEKEND
• Bell CM: Mortality among patients admitted to
hospital on weekends as compared to weekdays
N Engl J Med 2001, 345(9):663
- 3,789,917 admissions
- Ruptured AAA, acute epiglottis, pulmonary
embolism
- Weekend admissions had significantly higher
hospital mortality rates.
DAY OF THE WEEK
• Barnett MJ: Day of the week of ICU admission
and patient outcome: multi - site regional
evaluation
Med Care 2002, 40(6):530
- 156,136 ICU admissions in 28 hospitals
- weekend admissions had 9% higher mortality
than mid- week admissions, but not when
compared to Monday and Friday
WEEKDAY vs WEEKEND
• Ensminger SA: The hospital mortality of patients
admitted to the ICU on weekends
Chest 2004, 126(4):1292
- 8,101 ICU admissions
- Weekend ICU admissions had higher risk
adjusted mortality than weekday ICU
admissions in the surgical ICU, but not in
medical ICU
DAY vs NIGHT
• Morales IJ: Hospital mortality rate and length of
stay in patients admitted at night to the ICU
Crit Care Med 2003, 31(3):858
- 6,034 patients admitted to MICU Mayo Clinic
- Night admissions had lower risk adjusted
mortality, MICU LOS and hospital LOS
- Heavy workload equalize mortality rates and
LOS
WEEKDAY vs WEEKEND
• Arabi Y: Weekend and week night
admissions have the same outcome as
weekday admissions to MICU with on- site
intensivist coverage
Crit Care Med 2006, 34(3):605
- 2,093 ICU admissions
- No difference in hospital admission rates
among the three time periods
DISCHARGE TIME
• Beck DH: The effect of discharge time, discharge
TISS score and discharge facility on hospital
mortality after intensive care
Intensive Care Med 2002, 28(9):1287
- High acuity premature an late discharges are
associated with high mortality
DISCHARGE TIME
• Tobin AE: After hours – discharges from intensive
care are associated with increase mortality
Med J Aust 2006, 184(7):334
- 10,903 ICU discharges
- Patients discharged after 5:00pm have a higher
mortality
WORKHOURS AND EDUCATION
• Lim KG: Internal medicine resident education in
the medical ICU: The impact on education and
patient care of a scheduling change for didactic
sessions
Crit Care Med 2005, 32(7):1534
- 30 minutes sessions at 8:00am produces
much better testable results than the 60
minute noon session limited- to PGY 1s, and
possibly results in lower hospital mortality
WORK HOURS AND EDUCATION
• Afessa B: Introduction of a 14 hour work shift
model for house staff in the medical ICU
Chest 2005, 102(6):3910
- Comparing 24 hour call Q4d vs 14 hour shift
model
- No evidence of compromise in patient care or
house staff education
YOU ARE DREAMING
• Landrigan CO:Effect of reducing intern’s
work hours on serious medical errors in
ICUs.
N Engl J Med 2004,352(18):1838
- Reducing 24 hour shift length and
frequency reduced serious medical errors by
36%
WHERE AM I AND WHY?
*Pronovost PJ: Improving
Communication in the ICU using daily
goals
J Crit Care 2003, 18(2):7
-Less than 10% of house staff and
nurses understood the goals of care
- It took 6 weeks of daily goal
training to increase this to 95%
RN: BED RATIO
• Amaravadi RK: ICU Nurse - to- patient
ratio is associated with complications and a
resource used after esophagectomy
Intensive Care Med 200, 26(12):1857
- Increasing the nursing ratio above 2:1
does increase the risk of post operative
complications
MD: BED RATIO
• Dara SI: Intensivist-to-bed ratio: association with
outcomes in the medical ICU
Chest 2005, 128(2):567
- Patient care compromise occurs when a ratio of
1:15 is exceeded with ICU Los increasing
ATTENDING
• Pronovost BJ: Intensive care unit physician
staffing: Financial modeling of the Leapfrog
standard
Crit Care Med. 2004, 32(6):1247
- High intensity staffing improves mortality and
LOS with best case senario savings of
$13 million per year with an 18 bed ICU
VOLUME
• Kahn Jm: Hospital volume and outcomes of
mechanical ventilation
N Engl J Med 2006,355(1):41
- 20,241 medical ICU ventilator cases
- high volume hospitals had 37% lower death
rates
SPEED
• Bellomo R: A prospective before-and-after trial of
a medical emergency team
Med J Aust 2003, 179(6):283
- Getting ICU fellows amd ICU nurses to sick
patients anywhere 24/7 reduced cardiac arrests
65%, and hospital mortality 26% while 88%
of emergency ICU admissions
Brilli RJ, Kvetan V:
Teaching ICU Administration During
Critical Care Medicine Training- A
National Survey
Critical Care Medicine 2003, Vol. 29, No.
12 (Suppl.) A75
216 Program Directors
ACGME Accredited Programs In Anesthesiology,
Medicine, Pediatrics and Surgery
139 (64%) Responded
Formal Lectures Provided By
The CCM Program:
CCM Budget Development / Management
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Personal / Professional Development
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32%
Credentialing / Certification
33%
Hospital Administration
37%
Record Keeping / Compliance / Data
43%