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Hospital of the Future
Ognjen Gajic M.D.
Professor of Medicine
Attending Intensivist
Mayo Clinic
Rochester MN, USA
Multidisciplinary Epidemiology and Translational Research in
Intensive Care and Perioperative Medicine (METRIC - PM)
• Interdisciplinary group of interested in epidemiology and translational research in critical illness and life support interventions
• Funded by
• CMS
• NIH
• Mayo Foundation
• Philips Research North America
Disclosure
©2010 MFMER | slide-3
“The fundamental problem with the quality of medicine is that we’ve failed to view delivery of health care as a science”
• The tasks of medical science fall into three buckets.• understanding disease biology
• finding effective therapies
• insuring those therapies are delivered effectively
• That third bucket has been almost totally ignored. It’s viewed as the art of medicine.
• “That’s a mistake, a huge mistake”
Peter Pronovost http://www.letstalkhealthcare.org/health-care-costs/how-a-checklist-can-improve-health-care/
Science of Health Care DeliveryDefinition
“The scientific study and
the practical application of
processes for maximizing
the value of healthcare”
From the SHCD retreat document, Nov 8th, 2007, MCJ
Martinez EA, Marsteller JA, Thompson DA, et al. The Society of Cardiovascular Anesthesiologists' FOCUS Initiative: Locating Errors
Through Networked Surveillance (LENS) Project Vision. Anesth Analg. February 1, 2010;110(2):307-311.
Science of Health Care Delivery
Informatics
Pickering et al Crit Care 2012
Critical care support for
potentially reversible acute illness
One of the most cost-effective
healthcare interventions
Incomplete
knowledge
Delayed, error-
prone care
delivery
Courtesy Dr Kilickaya
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series
white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006. Available on
www.IHI.org
Probability of Performing Perfectly
Courtesy Dr Yoel Donchin
1978 Dec;49(6):399-406.
Patient Safety: Importance of Human Factor Engineering
Patient Safety in Critical Care: the Declaration of Vienna
• Human factor and ergonomics
• Regionalization/volume
• Adequate staffing
• Safety culture/teamwork• Nurse-physician communication
• Interprofessional rounds
• Handover
• Checklists
• Teams: RRT…
Moreno at al 2009
Carayon, P., Human factors in patient safety as an innovation, Applied Ergonomics (2010),
Domains of Human Factor Engineering
Determinants of Safe Health Care Delivery
Pickering B et al. Applied Clinical Informatics 2010
Definition of Ambient Intelligence
• Ambient intelligence (Ami) and smart environments (SmE)
“Environment that proactively, but sensibly, assists
people in their daily lives”
N Engl J Med. 2002 Oct 17;347(16):1242-7
The promise of information techonology
Medical Records
1920 2012
Herasevich et al Mayo Clinic Proc 2010
Informatics Infrastructure
Smart Alarms
Herasevich et al Crit Care Med 2011
Results
• The exposure to injurious ventilation decreased• Median 41hr to 27hr, p=0.004
• The number of pages declined over time• RTs knew they were going to be paged
Herasevich et al Crit Care Med 2011
Point of Care Decision Support for Transfusion
Rana R, Afessa B, Whalen F, Keegan M, Nuttall G, Evenson L, Hubmayr R, Winters J, Moore S, Gajic O. Crit Care Med 2006
• ~1000 less transfusions in three months
• Decrease in transfusion related complications
• 6.1% vs 2.7%, p=0.015
Rana R, Afessa B, Whalen F, Keegan M, Nuttall G, Evenson L, Hubmayr R, Winters J, Moore S, Gajic O. Crit Care Med 2006
Gentle Reminder (“Nudge”) for RBC Transfusion
Han, Y. Y. et al. Pediatrics 2005;116:1506-1512
Poorly designed electronic systems can kill!
Indiscriminate Data Display Impedes Decision Making
Information Overload
MEAN Data Points/Day Per Patient Per 24 bedded ICU
Labs 60 1440
Drug Orders 10 240
Microbiology 2 48
X ray 2 48
Vitals 1950 46800
Pickering and Herasevich – Data generated in first 24 hours of ICU admission –Unpublished
BOTH PATIENT KNOWLEDGE AND
MEDICAL KNOWLEDGE
Control
Experimental
AWARE(Ambient Warning and Response Evaluation)
CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness)
and
DEATHDiagnostic Error and Therapeutic Harm
to prevent
AWARE information packages
B) Historical
Contextual Data
E) Provider
Actions/support
A) Organ
Identifier and
status
C) Current
Organ
Physiological
Status
D) Status of
relevant
investigation
Error-Resistant Checklist and Task List
Critical Care Choreography
Critical Care Choreography
Critical Care Choreography
Methodology for developing and testing ambient intelligence
Testing Ambient Intelligence: Safe Environment
Pickering B et al. Applied Clinical Informatics 2010
Reduced cognitive load and errors
Improved Efficiency
Standard Interface
Novel Interface
Ahmed A et al Crit Care Med 2011
Cloud AWARE
• Systematic review of
electronic decision support
1976-2010
• 311 unique studies (144
RCTs); majority outpatient
• Improvement in care
processes (prescribing
practices): OR 1.6 (1.4-1.7)
• Inconsistent effect on
outcome and cost
• Provision of decision support at time of decision making
• Provision of a recommendation, not just an assessment
• Integration with charting or order entry system
• Promotion of action rather than inaction
• No need for additional clinician data entry
• Justification of decision support via research evidence
• Local user involvement
• Provision of decision support results to patients
Features associated with success of CDSS
AHQR Technology Assessment 2012
Telemedicine: Sharing Critical Care Expertise
©2010 MFMER | slide-40
http://eicu.mediaroom.com/index.php?s=28705&mode=gallery&cat=2111
From: Impact of Telemedicine Intensive Care Unit Coverage on Patient Outcomes: A Systematic Review and
Meta-analysis
Arch Intern Med. 2011;171(6):498-506. doi:10.1001/archinternmed.2011.61
Effect of telemedicine intensive care unit coverage on in-hospital mortality and hospital LOS
Redesigning Workflow
Hospital of the Future
• Ambient intelligence• Human factor engineering and ergonomics
• Safety culture
• ”Less is more" - do away with iatrogenic waste
• Portable noninvasive diagnostics (bedside critical care ultrasound)
• Staffing/regionalization/telemedicine
• Patient/family centered care
• Death of hospital ward - ICU with early rehabilitation instead
©2010 MFMER | slide-43
Pickering et al Crit Care 2012
Portable noninvasive acute care diagnostics
©2010 MFMER | slide-45
Mount Sinai School of Medicine
Temple University School of Medicine
The Johns Hopkins University
University of Medicine and Dentistry of New Jersey
Denver Health Medical Center
Hospital of the University of Pennsylvania
Brigham and Women's Hospital
Mayo Clinic Rochester
U of Michigan University Hospital
University of Washington, Harborview Medical Center
Parkland Health and Hospital System Dallas, Texas
University of Illinois at Chicago
Wake Forest University Health Sciences
Mayo Clinic Jacksonville
Bridgeport Hospital, Yale New Haven Health
Massachusetts General Hospital
Akdeniz University Hospital, Turkey
Beth Israel Deaconess Medical Center
Miami Valley Hospital
Emory University, Atlanta
Uludag University School of Medicine, Turkey
University of Missouri - Columbia
National Infrastructure for Critical Care Research
• The first USCIIT Group study in 22 hospitals who joined USCIITG-LIPS1
• Researchers in emergency medicine, trauma surgery, anesthesiology and pulmonary/critical care medicine
http://www.usciitg.org/
Tracking and feedback
©2010 MFMER | slide-47
Adherence to Lung Protective Mechanical Ventilation
• Height and gender are known to be better predictors of lung size than is actual body weight
10
20
% T
LC
*
10 20
Vt mL/kg predicted body weight
10
20
% T
LC
*
10 20
Vt mL/kg actual body weight
Holets SR, Hubmayr RD. How to set the ventilator 2006
Creating Ambient Intelligence
4 5 6 7 8 9 1011 1314 16 1819
Vt m L/ kg PBW
4 5 6 7 8 9 1011 1314 16 1819
Vt m L/ kg PBW
NOT SAFE
NOT SAFE
Ventilator settings % ARDS Mortality
33%
9.6%
28.3%
18%
ARDS Prevention?
Point of care decision support
Science of Health Care Delivery
Pickering et al Crit Care 2012
ICU layout
Practice Monitoring and Feedback
The Checklist