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Background Intervention Results Brief Comments Reducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. Andreas H. Taenzer The Geisel School of Medicine at Dartmouth Dartmouth Hitchcock Medical Center October 26, 2012

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Page 1: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Reducing ICU Transfers and Rescue Events in theGeneral Care Area by Continuous Monitoring.

Andreas H. Taenzer

The Geisel School of Medicine at Dartmouth

Dartmouth Hitchcock Medical Center

October 26, 2012

Page 2: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Disclaimers

No compensation of any sort from any company.

Grant from the Anesthesia Patient Safety Foundation to studyrespiratory rate monitoring for patients on general care areas.

Government grants (FDA, NIH) for unrelated research.

Page 3: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Dartmouth

20,000 Inpatient Discharges

90,000 Inpatient Days

8,500 Intermediate CareDays

24,000 ICU Days

We currently have 3 Rescue Events and 1 Care Escalation per1,000 patient days.

Page 4: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Page 5: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

UCL=14.784

LCL=-5.657

CEN=4.564

UCL=5.889

LCL=-0.698

CEN=2.5955

-10

-5

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Rescue Events per 1,000 patient days per month over 2 years. Control limits adjusted for time of Start of Patient Surveillance.

Patient Surveillance

Page 6: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Infrastructure

Page 7: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Infrastructure

over 10x109 data points

over 10,000 patient days of physiologic data sampled inone-second intervals.

for adverse event review and research

Page 8: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Infrastructure

Vocabulary

Condition vs. Surveillance Monitoring

False Alarms - Nuisance Alarms - Actionable Alarms

Alarm Burden - Alarm Fatigue - Alarm Mismanagement

Rescue Events = RRT activations + Code Blues + Codes

Care Escalations/ICU Transfers = Unanticipated Transfer of aPatient to a Higher Acuity Care Unit

Page 9: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Alarm Settings

PSS Settings

Alarm Settings

SpO2 < 80

HR < 50

HR > 140

Alarm adjustments

1 Standard Settings

2 Bracketed Adjustments (±10%) by RN

3 Physican ordered Adjustment

Notification Delays15 sec at the bedside +15 sec (=30 sec total) for pagerannunciation

Page 10: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Description of Normality

40 60 80 100 120 140 160 1800

0.5

1

1.5

2

2.5

3

HR (bpm)

Pro

port

ion o

f T

ime S

pent (%

)

HR Histogram Comparison

Medicine

Surgery

70 75 80 85 90 95 1000

2

4

6

8

10

12

14

16

SpO2 (%)

Pro

port

ion o

f T

ime S

pent (%

)

SpO2 Histogram Comparison

Medicine

Surgery

Page 11: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Original Study

Decrease of Rescue Events by 65%

Page 12: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Original Study

Decrease of ICU Transfers by 45%

For each of the 32-bed surgical units, ICU days decreased by 160for the 12 months after implementation.

Page 13: Reducing ICU Transfers and Rescue Events in the General ... · PDF fileReducing ICU Transfers and Rescue Events in the General Care Area by Continuous Monitoring. ... SpO 2 (%) Proportion

Background Intervention Results Brief Comments

Three Surgical Units

Decrease of Rescues by > 50% across all Surgical Units

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Background Intervention Results Brief Comments

Respiratory Rate Monitoring

RR vs. SpO2

Data based on 5,000 patient days.

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Background Intervention Results Brief Comments

Developing Prediction Algorithms

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5C

tl.

HE

RT

PA

ll

HE

RT

−4h

r

HE

RT

−2h

r

HE

RT

−1h

r

HE

RT

−30

m

SpO2 Standard Deviation, Prior to HERT Comparison

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Background Intervention Results Brief Comments

Developing Prediction Algorithms

Not so easy...

Classifier Sensitivity (%) Specificity (%)

Naive Bayes’ 64 73Neural Network 70 59Sample Entropy plus NB 78 60NB in resp. subset 75 63

Data from c©Dr. Joshua Pyke’s PhD Thesis

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Background Intervention Results Brief Comments

Final Comments

Summary

DHMC has seen a sustained reduction in ICU Transfers and RescueEvents since the Introduction of Patient Surveillance despite an everincreasingly challenging patient population.Changes have been overall bigger on surgical than on medical floor.The most important factor of success has been degree of utilization.

1 Collaborative effort by all stakeholders involved(Administration, IT, RNs, Physicians, Engineers etc.)

2 Education for RNs and physicians

3 Continuous monitoring on all surgical and medical unitsincluding pediatrics (and planned roll out to ER and OB)

4 Patients have to sign waivers to not be monitored