2017 Hospital Quality Institute Vanguard Award Application Hospital: Sharp Chula Vista Medical Center 751 Medical Center Court Chula Vista, CA 91911 www.sharp.com

Contact Person: Liliana Stuart, MA, Lean Six Sigma Black Belt Clinical Effectiveness Office: 858-499-3103 Email: Liliana.Stuart@Sharp.com Kimberly Johnson, BSN, RN-BC, CCRN Clinical Lead Nurse, MICU/SICU - Sharp Chula Vista Medical Center Office: 619.502.5888 Email: Kimberly.Johnson@sharp.com

Title: Length of Stay Committee Initiative: Increasing ICU Bed Availability for the Highest Acuity Patients

Topical Area:

Quality Improvement Patient Experience Patient Safety

Support of Application: Our hospital’s Length of Stay (LOS) Committee was mired in reviewing data year after year with no significant actionable outcomes. Approximately a year and a half ago we revised the committee with a mandate to produce outcomes that would reduce our length of stay from our current average of 5 days to the national average of 4 days. We attacked this using both Lean Six Sigma and HRO (high reliability organization) tools. We found significant opportunities in physician practice patterns, nursing practice patterns, case management and social work processes, and information technology utilization. We formed subcommittees to work on specific areas, one of which specifically involved ICU throughput. This team, primarily composed of bedside and charge nurses, identified multiple barriers to efficient ICU throughput and developed effective strategies to address them. The results to date are impressive, and sustained. We are already spreading these practices to other units in the hospital. When I started this project, I was primarily concerned with throughput in order to increase access and decrease emergency room boarding. However, when we presented this project at our system Lean Six Sigma report-out to leaders meeting, I received a note from one of our IT staff members. She thanked me for working on this project specifically because she was still suffering PTSD from an ICU stay 10 years ago. She noted that her care was excellent; however, just the experience of every day in the ICU was so traumatic that she was still suffering. This brought home another reason why projects such as this that return the patients to home to be productive, fulfilled and happy as soon as possible are so critically important.

Lynn Welling, MD, FACEP Chief Medical Officer Sharp Chula Vista Medical Center

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Executive Summary

As part of Sharp HealthCare, the largest healthcare system in San Diego with four acute care hospitals, Sharp Chula Vista Medical Center is a 343-bed hospital and the largest health provider in San Diego’s South Bay. In order to meet the growing needs of the community, the leadership team is dedicated to continuous improvement. The ICU Throughput Initiative began in 2016 to improve patient flow and increase ICU bed availability for the highest acuity patients. The Length of Stay Committee, a multidisciplinary team lead by the Chief Medical Officer and a Lean Six Sigma Black Belt with the participation of hospitalists, emergency medicine doctors, nursing, and case management, is at the core of the project.

Overall, the ICU LOS was reduced by 14.3% from 3.5 days in 2015 to 3.0 days in 2016. We are proud to report that we have sustained these results throughout 2017. More specifically, we have reduced LOS for intubated patients by 24.7%, and by implementing evidenced-based practice initiatives, we ended 2016 with the lowest ventilator days in the system. We also improved our throughput process on patients transferring from ICU reducing transfer times by 73%, and implementing a bedside handoff process to improve patient safety.

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Background and Relevance

With a limited number of physical beds, ensuring the highest acuity patients are not waiting for hours in the ED or in another floor when their required level of care has increased is a safety priority.

This initiative was vital to better utilize existing resources and ensure high reliability concerning each patient’s level of care and movement throughout the hospital during their stay.

At the beginning of the project, we had a challenge to access accurate data since the available reports provided only a portion of the hospital’s overall length of stay. However, we knew we had a problem by surveying the stakeholders and walking the process; we observed “ICU patients” with stable vital signs sitting up in a chair texting on their cell phones. While those patients were taking up an ICU bed, we had intubated patients holding unnecessarily for hours in the ED, or a septic patient that was quickly deteriorating on one of our telemetry units in need of an ICU bed.

We established a goal of reducing our length of stay by 10%, and collaborated with Sharp HealthCare’s corporate analytics team to acquire baseline data and design specific reports. We knew that a decreased ICU LOS would provide beds for more elective procedures and well-reimbursed surgeries, as well as reduce wait times in the ED improving our patient satisfaction data.

For decades, the thought process was that patients are safer in the ICU, and we absolutely have the opportunity to provide life-changing care to patients that require critical care. However If patients are not in need of it, current research indicates that ICUs can be unsafe places for patients not needing intensive acute care.

With Sharp’s pathway to be a High Reliability Organization, we are committed to zero defects and zero harm with each patient encounter and the appropriate level of care plays a significant role in this effort. Leaving the ICU decreases patients’ risk for nosocomial infections as well as their risk for delirium, which can affect them for their rest of their lives (Barr, et al, 2013). Furthermore, patients who stay in ICU for more than three days are at a higher risk for persistent depression, anxiety, and post-traumatic stress disorder after leaving ICU (Barr, et al, 2013).

LOS is a complex issue to tackle as multiple disciplines have significant influence over a patient’s timely transition from ICU to a lower level of care. To address this issue we assembled a multi-specialty team

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including attending and consulting physicians, nurses and charge nurses from ICU, our progressive care units (PCUs), case management, respiratory therapy, social work, and the centralized patient placement coordinators.

Project Description

Even with 28 medical and 7 surgical intensive care unit beds, there are often more patients in need of ICU beds than there are places to put them. One of the challenges of being a community hospital is the lack of an intensivist physician program to provide continuity within our critical care units, ensuring that patients are downgraded as soon as they no longer necessitate ICU level of care, as defined by the units’ policies and procedures. With any internal medicine physician or specialist being able to admit to ICU, it is not a surprise that our ICU length of stay needed improvement

The project scope is from the time patients arrive in MICU/SICU until the time that they leave the unit whether that be to another acute in-patient facility, long term acute care, or transfer to a PCU within the hospital.

Data Collection Plan: Based on guidelines delineated in our policy to admit or transfer patients to the ICU, we began to collect data as to why patients no longer meeting ICU criteria are not receiving transfer or discharge orders. We collaborated with physician leaders and created a list of potential reasons patients stay in the ICU longer than needed in order to identify the most common root causes and main opportunities for improvement to address with the responsible physicians. Each night, we evaluated patients for ICU criteria and the next day in the a.m. the Charge Nurse followed up on transfer orders for those not meeting guidelines, and assigned a reason from the list if no order was received, for documentation and tracking purposes.

One of the most significant opportunities for improvement identified was with ventilated patients. Through collaboration with respiratory therapy, we were able to ascertain that our these patients were staying in ICU twice as long after extubation than at other Sharp hospitals, so a portion of the project focused on improving outcomes for intubated patients

Specific interventions included the incorporation of evidence-based practice such as early mobilization of mechanically ventilated patients. A sub-group worked with pulmonologists to create a process for nurses to place an order for early mobilization if the patient met certain criteria. Through additional collaboration with physical therapy, we were able to get staffing adjustments to workflow in order to be able to facilitate this process change. Additionally, a daily process was established to coordinate spontaneous awakening trials each shift with spontaneous breathing trials to better facilitate liberation from the ventilator.

2015 LOS for SCV Ventilated Patients: 7.3 days (the highest in the system) 2016 LOS for SCV Ventilated Patients: 5.5 days (the lowest in the system) Reduced by 24.7 % or 1.8 days

Voice of the Customer: Through interviews with multiple specialties, we identified opportunities for improvement on both the physician and nursing portions of the throughput process.

Opportunities for physician improvement included:

Lack of standardized processes to contact and coordinate care between attending physicians and consulting physicians

Late rounding from attending physicians resulting in delayed transfer and discharge orders Lack of early coordination with discharge planners to overcome placement obstacles Breakdown in direct communication between physicians, nurses, and discharge planners resulting in

avoidable throughput delays

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Among patients that receive an order to transfer from the attending physician, there was a lack of specificity as to which (if any) consulting physicians need to approve of any given downgrade

Opportunities for nursing improvement included:

Lack of knowledge regarding the risk of staying in ICU when it is not medically necessary Lack of coordination with other units for transfer to a lower level of care No accountability process to enforce pre-agreed timelines for transfers Inconsistent methods for addressing level of care with physicians and lack of participation in rounding

with them and case management Variation in throughput resulting in bottlenecks extending patient wait times

Strategies and Tactics

Current State Analysis: process mapping identified gaps, inconsistencies, and duplication of tasks resulting in “wasted time” and no value added activities

Needs Assessment: confirmed opportunities for targeted education to reduce avoidable delays. Clinical nurses performed one on one in-services with their colleagues to facilitate early adoption and implementation including:

o Guidelines for admission to ICU to better facilitate daily conversations with physicians regarding appropriate level of care

o Accurate patient attributes (isolation status, dialysis, 1:1 sitter, etc.) in Teletracking so that an appropriate bed assignment by the remote coordinator is made the first time preventing an inappropriate bed assignment that could jeopardize the patient’s safety

o Standard work roles for sending unit (ICU) and receiving unit (PCU) charge nurses, resource nurses, unit clerks, and bedside nurses for streamlined throughput process

o Real Learning Solutions (quality variance reports) expectation for inappropriate level of care extended stays

Dedicated ICU case manager to expedite discharges: instead of rotating case managers, providing greater continuity of care

High-level value stream process: exposed opportunities for improvement within the influence of nursing and ancillary services. With a limited bed capacity, mostly semi-private rooms, and staffing challenges there are many obstacles to throughput that we were unable to directly control. On average, an ICU patient waits for a telemetry bed 16.8 hours after receiving a transfer order, but once a clean bed is assigned, the time a transfer takes is directly within ICU control.

o Sharp Chula Vista had the longest transfer times in the system to move a ICU patient with a transfer once a clean was assigned.

o Transfers from ICU to PCUs averaged 1.5 to 2 hours from the time the bed was assigned until the time the patient arrived. This is non value added time to the patient and exceeded the system goal of < 30 minutes.

o Through collaboration with Centralized Patient Placement, a team of bedside clinicians, and nurse leaders from multiple units, a data driven process was developed to evaluate baseline performance, identify gaps and propose improvements.

o Throughput times were decreased by over 73% through collaborative interventions:

Standard work roles created for both ICU and receiving units

Future state process map created for streamlined work flow

Custom Teletracking reports created to track progress by unit on a weekly and monthly basis

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Dual monitor displays for unit clerks on all units to view assigned beds while completing other tasks

Challenges Addressed

Physician practice patterns proved to be one of the most elusive to study and analyze, and very difficult to change. Our ICU physician-staffing model is currently an open model, with any physician with active admitting privileges eligible to admit to the ICU. We interviewed a sample of physicians with the longest length of stays, and those with the shortest and mapped their process. We looked for practice patterns that may contribute to both long length of stays and the most efficient hospital stays. We found that those with long lengths of stays tended to be more passive in managing their ICU course, deferring much of the decision making to multiple consultants. They also failed to coordinate the care between those consultants. They were most likely to extend the ICU care for “one more day” without good clinical justification. These physicians also rounded later in the day and fewer times per day and wrote orders when they returned to their offices later in the day. All of this contributed significantly to extended ICU lengths of stay.

We addressed this by targeted interventions and showing best practices and their data compared with the other physicians with better LOS outcomes.

We shared our challenges with the medical executive committee and received approval to contact physicians at 0700 with a list of their patients that based on mutually supported criteria should be able to be discharged or transferred that day, and ask them to round on those patients first when to expedite the process.

We changed our order sets and eliminated the order: “discharge when ok with the consultants” to place responsibility on the attending physician. If there is a specific consultant that needs to give input, the attending must specifically list that consultant. Nurses then proceed to follow up with that consultant to ask for their approval to discharge.

We have improved the physician dictation stations on each unit, and asked the physicians to write orders prior to leaving the floor and empowered nurses to request all orders prior to the physician leaving.

These interventions have had positive effect in enabling physicians to be more effective, and have had an effect on reducing ICU LOS. Of note, we have also recently contracted with an intensivist group who will be co-managing all ICU patients with their primary physician. We believe this will have significant impact on the quality of care along with the efficient provision of care.

Results of the Efforts

We were able to decrease our average length of stay from 3.5 days in 2015 below our goal of 3.15 days to 3.0 days through December of 2016, which was a decrease of 14.3% meeting our goal. December 2016 was the first month that ICU’s LOS averaged 1.8 days from admission to downgrade order; and was lower than any single month in 2015.

A decrease of 0.5 days or 12 hours is a step in the right direction, and can make a difference for patients spending another night with interrupted sleep and its highlighted risks. More than likely this improvement will be significant for the numerous patients waiting in the ED for an ICU bed or those patients with Sharp insurance that are at other area hospitals needing to be transfered into the Sharp system.

Significance of Results

In 2019, Sharp Chula Vista will be adding a new tower with over 100 in-patient beds, until then we have to work with the current resources. Ensuring that patients who can safely be downgraded leave the unit as soon

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as possible for patients that require the critical care ICU provides, is paramount to facilitating throughput throughout the hospital.

Another important outcome of this project is the increased satisfaction of the staff with the new process by empowering stakeholders (RNs, physicians and other units) to support and hold each other accountable without fear; thanks to leadership commitment and motivation from all involved to excel and contribute to our HRO (High Reliability Organization) pathway. A united team is a strong team.

Sustainability and Scaling of Achievements

Accountability via weekly review of data from automatically generated customized reports to evaluate transfer times

Weekly transfer times reviewed with leadership at hospital-wide Reliability Huddle each Monday Real-time coaching for deviations from standard work in transferring patients with a report of any

extended transport times in the ICU reliability huddle each shift Monthly LOS data presented to LOS Committee Commitment to track and manage a control plan to avoid going to old ways Stabilize and sustain gains achieved by analyzing and addressing outliers through variance reports that

are escalated to peer review when appropriate

Lessons Learned

Including key stakeholders from all involved disciplines and departments in the beginning of the project is essential to ensure buy-in.

Ongoing tracking of variances and follow-up of outliers when they occur is essential to sustainability. Support from an executive sponsor is vital to engage physicians in changing their old ways and to

promote collaboration with the multi-disciplinary team. Multiple iterations of educational in-services through various venues are essential to broaden

implementation beyond the early adopters. A strong team leader with dogged determination to keep on track is critical to success. Technology (Teletracking) is important, but not the ultimate answer. Mid-level leaders (charge nurses) need to understand and commit to throughput in the face of

competing priorities

Reference:

Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., & ... Skrobik, Y. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. In Critical Care Medicine 41(1), 263-306.

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SCV SGR SMH

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Sharp HealthCare hospitals with > 50 vented patients

Vent Days vs. ICU Days May 2016

Vent Days (Avg Per Person)

ICU Days (Avg Per Person)

ICU Stay After ExtubationSCV: 2.1 days post-extubation

SMH: 1.4 days post extubation

SGR: 1.0 days post-extubation

Attachments:

Overall Length of Stay for 2015 from admission until the patient physically leaves the unit: reduction of 14.3%

This baseline data indicated a singificant opportunity with ventilated patients. In constrast to the graph above,

post intervention SCV patients had the lowest ventilator days in the system as well as the lowest Length of Stay.

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SCVMC MICU/SICU was averaging an additional 1.5 to 2 hours from the time that a clean, staffed bed is

assigned until the time the patient arrives in his or her new telemetry room. None of this time added value to the

patient and greatly exceeds the Sharp system goal of < 30 minutes. These transfer times are especially

important as the average time our patients spend waiting for their telemetry bed is 16.8 hours. SCVMC

MICU/SICU was able to decrease transfer times from 1.5 to 2 hours to meeting the goal of averaging less than

30 minutes on all transfers out ICU in December 2016. We continued to sustain our progress through May 2017.

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The project team utilized this high level tool during the early phases of the project.

In analyzing our current state workflow and process, we identified numerous causes of our patients being here

longer than they require. The starred barriers were addressed early in the project:

Patients are spending at least one extra day

longer on avaerage in ICU than medically

necessary

People/Staff Methods/Processes

Environment Machine Material

Higher patient/nurse ratio on PCU and acute care

Nurse's preference not to have to transfer then immediately admit

Physician's concern about legal implications or family preference

Inconstistant Nurse/Physician/Case Management Interaction

Lack of assigned nurse, inconsistancy in nurse to nurse handoff, and

inconsistant step down staffing on PCUs

Consistantly high in-patient census

Incorrect Bed Assignment in Teletracking

Lack of Insurance coverage

Pending labs, diagnostic tests, procedures, etc.

Inconsistancy among attending physicians as to which (if any) consulting physicians need to approve

transfer

Lack of knowledge about risk of staying in ICU when not necessary

Weekends, holidays, and covering physician delays

Limited bed capacity contributes to delay in transfer to lower level

of care

Patient preference for private room

Lack of Transportation for Discharges

Cause and Effect

Fishbone

SIPOC

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Day

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Month 2015 vs. 2016

MICU Admit to Transfer Order Month by Month Comparison2016 2015

↓ Good

Y= LOS (mean)

Average Wait for PCU Bed once downgrade

order is entered: 16.8 hours

A month by month comparison for 2015 vs.2016 post-implementation for admission time until transfer/discharge order time.

Overall reduction of 0.5 days

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Month 2016 vs. 2017

MICU Admit to Transfer Order Month by Month Comparison2017 2016Y= LOS (mean)

Sustainment of Achievement: after transitioning to the control phase in

January 2017 we've maintained our gains from admission to downgrade order