university of michigan health system – emergency critical

UniversityofMichiganHealthSystem–EmergencyCriticalCareCenter

BenBassin,KyleGunnerson,JenniferGegenheimerHolmes,ReneeHavey,CemalSozenerandSangeetaVijayagopalan

AppendixA

Figure1:PreandPostEC3ImplementationPatientFlowModel

Figure2:EC3StaffingModel



Figure3:EmergencyCriticalCareCenterFloorPlan

Figure4:EC3ProjectTimeline



Figure5:EC3StaffHiringTimeline

HIRING

1month

TRAIN

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

1.0FTE1.0FTE1.0FTE1.0FTE1.0FTE1.0FTE1.0FTE1.0FTE1.0FTE

1.0FTE1.0FTE

9CriticalCareBe

dsA

ctivated

EC3+Re

susF

ullyOpe

ratio

nal

RN

PhysAsst

Clerk

9months

HIRING 9bedsavailable-February2015

EC3STAFFHIRINGTIMELINE:Nursing-Tech-Clerk-PA-RT-NursingSupervisor-NurseEducator

3months 6monthsTRAIN

2months

HIRING

6months

HIRINGRT

RN29.0FTE

Internship-12FTE(turnover/EC3)

PhysicianAssistant9FTE

1.0FTE

1.0FTE

Clerk5.5FTE

RespiratoryTherapist5.5FTE

Internship-12FTE(EC3staffing) 1.0FTE

1.0FTE

1.0FTE

1.0FTE

1.0FTE1.0FTE

1.0FTE

3months

TRAIN

1.0FTE1.0FTE1.0FTE

1.0FTE

1.0FTE

2months

TRAIN

1.0FTE

MILESTONES

1.0FTE

ProjectCompletion-May2015

14.3experiencedRNtobehiredasavailable(EC3andturnover)

1.0FTE

NurseEducator

1.0FTE1.0FTE

1.0FTE

1.0FTE

1.0FTE

NursingSupervisor

1.0FTE1.0FTE

Resucitatio

nBa

yRe

novatio

n

1.0FTE1.0FTE1.0FTE1.0FTE0.5FTE1.0FTE1.0FTE1.0FTE1.0FTE1.0FTE0.5FTE



Figure6.OverallEC3OperationalOutcomesIncludingPatientDispositionandPathwayUtilization• 70.1%ofallpatientstreatedinEC3havebeenadmittedtoatelemetryunit,generalcareunitor

dischargedfromtheEDcreatingsignificantinstitutionalcapacityforcriticalcareadmissions• 1.1%ofpatientstreatedinEC3haveexpired,manyofwhomreceivedpalliativecareservicesin

EC3.Overall,theEC3caremodelhasproventobesuccessfulinplayingaroleinareductioninICUadmissionfromtheED.ComparingtheoneyearpriortoEC3opening(Feb2014-Feb2015)totheoneyearafterEC3opened(Feb2015-Feb2016),anoverallincreaseinEDvisitswasnoted(+5.7%),aswellasincreaseinhospitaladmissions(+7.2%).DespitethisincreaseinEDvolumeandadmissions,theoverallnumberofICUadmissionsdecreasedby12.4%.ThisequatestoanICUadmissionratereductionacrossallEDvisitsfrom2.5%to2.1%representinga17%relativeriskreductionornumberneededtotreatof235.Anotherwayofinterpretingthisistosaythat4ICUadmissionscouldbesavedforevery1,000EDpatientsseen,soanEDwithanannualvolumeof100,000patientswouldsaveapproximately1,000ICUbeddaysperyear.



Figure7:PreandPostEC3ImplementationEDVisit,HospitalAdmissionandICUAdmissionRates

Figure8:EC3isassociatedwithadecreasedICUadmissionratefromtheED.1ICUadmissioncanbesavedforevery235EDpatientsevaluated.Despiteearlyimpressiveresults,wewantedtoensurethatthestrategyofadministeringearlyaggressivecriticalcareintheEDwithresultantICUadmissiondecreasewasasafeone.WesoughttoprovethatthisearlydowngradingfromICUtonon-ICUhospitaladmissionwasnotassociatedwithahigherbouncebackratefromthefloortotheICUemergentlywithin24hoursofEC3admissionduetopatientsbeingdowngradedtooearlyintheirdiseasecourse.Additionally,weinvestigatedanychangesin48hourmortalityinthepreandpostEC3periodasthiswouldlikelybemostassociatedwithcareprovidedinthetimeframeinwhichthepatientwasintheED/EC3.7dayand30daymortalityareofinterestaswellbutitsmoredifficulttopredicttheimpactofED/EC3careonmortalitysignificantlyremovedfromthecareadministeredatthebeginningofhospitalization.



Inlookingatbothrateofemergenttransferfromfloor(ward)toICUwithin24hoursofEDadmissionand48hourmortalityrate,therewasnosignificantchangebetweenthepreandpostEC3period.ThissuggeststhattheEC3caredeliverymodelisasafeoneanddoesnotresultinprematuretransfertoalowerlevelofcarefromtheEDoranincreaseinshort-termmortality.

Figure9:NoincreaseinemergenttransfersfromwardtoICUisseenwithin24hoursofEDadmissionsuggestingtheEC3caredeliverymodelisasafestrategyanddoesnotresultinprematureadmittanceofsickerpatientstonon-ICUenvironments

Figure10:Noincreaseinshort-termmortalitynotedafterimplementationofEC3modelAnadditionaltargetmetriclookedatICUadmissionsfromtheEDoflessthan24hours.These“shortstay”ICUadmissionsmayreflectinefficientuseofICUresourcesandwereapotentialpopulationthatEC3couldimpact.IfaggressivecriticalcarecouldbedeliveredintheED/EC3,patientsmayhavearapidenoughimprovementthattheywouldnolongerrequirethesebriefstaysintheICUallowingICUbedstobesavedforthesickestpatientswhowillrequirethelongesthospitalstays.ComparingthepercentageofEDtoICUadmissionsthatstayedintheICUforlessthan24hourspreandpostEC3openingshowsadecreaseofalmost40%.



Figure11:ReducedICUadmissionsfromEDthataretransferredtofloorin<24hours.39.7%decreaseinthenumberofcasesadmittedtoanICUandtransferredouttoageneralcareunitinthefirst24hoursofadmissionascomparedtoYTD(yeartodate)2015.ThisallowsICUresourcestobeconservedforthesickestpatientswiththelongestICUlengthofstay.Finally,weundertookasub-analysisofEDtoICUadmissionspreandpostEC3openingthatonlyinvestigatedpatientsgoingtothetwomedicalICUs(theCriticalCareMedicineUnite(CCMU)andtheCardiacCriticalCareUnit(CCU)).ThisisimportantbecausewehypothesizedthattheEC3caremodelwouldmostimpactmedicalICUadmissionsbecausepatientsrequiringimmediatesurgeryorsurgerysubspecialtycarewouldbelesslikelytohavetheircaretrajectoryalteredbythecareabletobedeliveredinEC3.Earlyresultsshowanimpressive36.4%reductioninEDtoCCMUadmissionsanda33.3%reductioninEDtoCCUadmissionpreandpostEC3implementation.NotonlywereICUadmissionsfromtheEDabletobereducedbutthisthencreatedadditionalICUcapacityforoutsidehospitaltransfersdirectlyintotheICUstoallowourhealthsystemincreasedopportunitytoprovidecomplexpatientcareandgeneraterevenuefromthisincreasedinpatientICUcapacity.



Figure12:SignificantReductioninMedicalICUandCardiacICUAdmissionsafterEC3OpeningMedicalICU(CCMU)admissionsfromtheEDhavedecreased36.4%sinceEC3openedwithacorresponding26.8%increaseinpercentofOSHtransfersdirectlyintoCCMU.CardiacCriticalCareUnit(CCU)admissionshavedecreased33.3%.

university of michigan health system – emergency critical

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