Bl d d M T l tBlood and Marrow Transplant ICU Utilization ...cmesyllabus.com/wp-content/uploads/2017/03/Day-2-Updated-Presentation-Jenkins-Trisha.pdfSource: (CY's: BMT Admin) (FY 2008-2016:

Bl d d M T l tBlood and Marrow Transplant ICU Utilization Project

Stanford BMTStanford BMT

March 2017

Disclosures

I have nothing to disclose I have nothing to disclose.

Confidential – For Discussion Purposes Only 2

The Question is……Can we do this?Can we do this?

− just one more test, treatment, or research protocol to offer)

Should we do this? − based on patients wishes, values & goals

In serious Illness, medical care is often mismatched with the patient values

This mismatch can cause big problems and unnecessary costs

Confidential – For Discussion Purposes Only

This mismatch can cause big problems and unnecessary costs

3

Measure & Analyze the problem

Average BMT ICU LOS per Case

14 00

6 89

11.68

8.00

10.00

12.00

14.00Da

ys

4.19

6.89

4.84

0.00

2.00

4.00

6.00ICU

Upward trend in BMT ICU LOS in CY2006

0.00CY 2003 CY 2004 CY 2005 CY 2006

YearData Updated: 9/8/08Source: (CY's: BMT Admin)


Upward trend in BMT ICU LOS in CY2006

Measure & Analyze the problem

% Total ICU Days to Total Inpatient Days

6 0%

3.3%

5.1%

3.1%3 0%

4.0%

5.0%

6.0%ce

nt

1.5%

0.0%

1.0%

2.0%

3.0%

Perc

Upward trend in % BMT ICU Days vs

0.0%CY 2003 CY 2004 CY 2005 CY 2006

YearData Updated: 9/8/08Source: (CY's: BMT Admin)


Upward trend in % BMT ICU Days vs

Total BMT inpatient days in CY 2006

Defining the problem

A i t tili ti i iti l ith i d t d Appropriate resource utilization is critical with increased costs and scarcity of ICU Beds

Communication between medicals teams is often fragmented resulting in conflicting information to patients and families

Unclear communication makes it difficult for patients and families to make educated decisions

These factors can result in over utilization of the ICU for non-beneficial care


Major Findings from Stanford Study

A d i f i d i ti b t iA desire for improved communication between caregivers, patients, and families

47% f f ili f lt th i d t di t 47% of families felt they received contradictory messages

23% felt they received conflicting recommendations


Source: 1998 Stanford End of Life survey- Family Interviews.

Communication


EOL Discussions & Prognosis : Physicians

Don’t have the time - 66%

Not sure the time is right - 60% (not ready for PC or Hospice discussion)

Not sure what to say - 46%

No formal training 68% ASPEN FACUTY DEVELOPMENT Sept 2016


Difficult Discussions 71% f th ti MD k & 29% ti t/f il k 71% of the time MDs speak & 29% patient/family speaks

− The more the family speaks the higher they rate the meeting in meeting their needs

Need to: Need to:

−Listen & Listen more

Answer questions ft d t di tl th i ti−Answer questions – often we do not directly answer their questions

−Acknowledge & address emotions

−Address principles of Palliative care−Address principles of Palliative care-

such as patient preferences, explanations of options, surrogate decision making

we will offer comfort care & we will not abandon them

Confidential – For Discussion Purposes Only (White et al, 2010)10

Patient and Family Conferences

Th ti f b i li t d t iThe perception of being listened to is one of the greatest predictors of g pPatient and Family satisfaction


Project goals and benefits

PROJECT GOALS

Develop criteria to help determine when ICU admission and reevaluation is necessary

Decrease average ICU LOS without negatively impacting mortality

Decrease number of patients admitted to ICU when “No Stay Recommended” Decrease number of patients admitted to ICU when No Stay Recommended

Consistent evidence-based guidelines and tools for appropriate admission of BMT patients into ICU

PROJECT

Clarity of information and communication to patients and families enabling them to make educated decisions regarding care options

Improved patient, family and staff satisfaction

BENEFITS Appropriate utilization of ICU beds for BMT patients, thereby improving ICU throughput

Appropriate Resource utilization and deceasing costs

Avoid treating futile conditions that can result in unnecessary treatments


Avoid treating futile conditions that can result in unnecessary treatments and sometimes painful procedures and deaths

BMT ICU Clinical Admission Guidelines Intensive BMT Care Recommended Intensive BMT Care Recommended

− Veno-occlusive Disease (VOD)/Sinusoidal Obstructive Syndrome(SOS)− Hypoxemia not requiring intubation especially if volume overload or transfusion related acute lung injury

(TRALI)− Sepsis without hypotension− Hypotension− Diffuse Alveolar Hemorrhage (DAH) − Cardiac Event− Airway Protection

Limited ICU Recommended – reevaluate within three days of ICU admission

− Severe Sepsis requiring intubation or vasopressors− Respiratory Failure requiring intubation

No ICU Recommended− Grade 4 Graft vs. Host Disease (GVHD) unresponsive to aggressive treatment with respiratory failure

R l d di if t t t t i t ti


− Relapsed disease if recurrent treatment is not an option− Multi-organ Failure, requiring intubation (2 organs + mechanical ventilation)

Prognostication in BMT Patients Requiring ICU Care Counseling BMT pts with newer data needs to be predicated on Counseling BMT pts with newer data needs to be predicated on

probabilities from recent literature Probability of survival in pts mechanically ventilated ~15-30% Probability of survival in pts mechanically ventilated who require pressor

support is most commonly <10% and worsens with time Probability of survival in pts mechanically ventilated with hepatic and renal

f il i 5% d ith tifailure is <5% and worsens with time Pts and/or families should be told ahead of time and informed that re-

evaluation at 3-4 days will be important

Best references from 2003 onwards:− J Clin Oncol 24:643, 2006− Biol Blood Marrow Tx 12:301, 2006


− Chest 126:1604, 2004− Crit Care Med 31:1715, 2003

H i di i d i Ri k & B fit f Having discussions around poor prognosis, Risks & Benefits of treatment options, probabilities of survival and making recommendations around EOL decisions are difficult for MDs.

In BMT, with our long length of stays & close relationships with our patients and families, it is even harder. pa e s a d a es, s e e a de

In BMT it is often a final treatment option for a terminal diagnosis

Discussions about futile treatment options can be difficult for some providers and are often initiated too late and only after patient deteriorate or go to the ICU


deteriorate or go to the ICU

15

Prognosis: Patient Perspective

False hope is no hope

Often patients want to know

Absent explicit discussions, patients must infer

Information influences decisions

We would all live our lives differently if we knew we had only one year to live


Process Improvement : for BMT Patients Admitted to ICU

BMT Team utilizes the BMT ICU Guidelines for managing appropriate ICU Admissions.ICU Admission

ICURounding

BMT and ICU Teams meet for daily rounds during the patient’s stay in the ICU.

ICUFamily

Conferences

BMT and ICU Teams meet with the patient or family every 2-3 days during ICU stay to update & clarify goals of care.

BMT Monitoring Tool utilized to monitor adherence to admission criteriaBMT Patient


adherence to admission criteria. All ICU patients are reviewed monthly at the

BMT Review meeting.Review

Results

14 00

Average BMT ICU LOS per Case

11.68

9.61

8.00

10.00

12.00

14.00

ays

4.19

6.89

4.84

6.525.83

7.07

5.29

6.677.37

5.46

7.07

2.00

4.00

6.00

8.00

ICU

Da

0.00CY

2003CY

2004CY

2005CY

2006FY

2008FY

2009FY

2010FY

2011FY

2012FY

2013FY

2014FY

2015FY

2016YearData Updated: 2/20/17

Source: (CY's: BMT Admin) (FY 2008-2016: ICU Utilization Tool)


Decrease in BMT ICU LOS

Results

BMT ICU Utilization ICU Day Comparison

290180

307435

191 FY 2016

FY 2015

FY 2014

FY 2013

292215

442210

0 100 200 300 400 500

FY 2012

FY 2011

FY 2010

FY 2009

BMT ICU DaysFY 2009

FY 2008

CY 2006Data Updated: 2/20/17Source: (CY 2006: BMT Admin) (FY 2008-2016: ICU Utilization Tool)


Total BMT ICU Days per year

Results:BMT Project Utilization Impact: FY 2016

BMT Cases Transferred to ICU36 3634

40

BMT Cases Transferred to ICU

CY 2006

18

242121

36

16

24

19

36

2320

20

25

30

35

40

r of p

atie

nts

CY 2006

FY 2008

FY 2009

FY 201015

13

18

242121

11 11

15 16

24

19

2320

12

34

1215

20

25

30

35

Num

ber o

f pat

ient

s

CY 2006

FY 2008

FY 2009

FY 2010

FY 201115

9

1

13

2 1

11

2

11

3

15 16

3 30

12

3

0

5

10

15

Limited ICU Recommended ICU Recommended No ICU Recommended

Num

ber FY 2010

FY 2011

FY 2012

FY 2013

FY 2014

9

1 2 1

11

2

11

3 3 30

12

3

12

2

0

5

10

Limited ICU Recommended ICU Recommended No ICU Recommended

FY 2011

FY 2012

FY 2013

FY 2014

ICU Admission CriteriaFY 2015

FY 2016

Data Updated: 2/20/16Source: (CY 2006: Manual Chart Review) (FY 2008-2016: ICU Utilization Tool)

ICU Admission CriteriaFY 2015

FY 2016

Data Updated: 2/20/17Source: (CY 2006: Manual Chart Review) (FY 2008-2016: ICU Utilization Tool)


More Patients that were recommended for the ICU went to the ICU

RESOURCES/COST SAVINGS 20 t f 410 ti t d itt d t th ICU h 20 out of 410 patients were admitted to the ICU who

did not meet the criteria in 9 years(1 was admitted t i ) Ab t 5%twice) About 5%.

−Total of 108 ICU days were associated with these y20 patients

−Mean ICU LOS was 4 4 days (shorter)−Mean ICU LOS was 4.4 days (shorter)

−Assuming average ICU charge of ~$50,000/day h 20 “N ICU” i $ 5 illi !


those 20 “No ICU” patients cost over $ 5 million! 21

Decrease in % of ICU days to Inpatient BMT days

8 0%


7 0%


5.1%

7.1%

4.7%5.0%

6.0%

7.0%

8.0%

nt

5.9%

5.1%

4.5%

5.0%

6.0%

7.0%

t

1.5%

3.1%3.3% 3.5% 3.4% 3.4%

2.3%

4.1%

2.2%

3.4%

1.0%

2.0%

3.0%

4.0%

Perc

en

3.1% 3.1%

2.2%

3.4%

2.2%

2.7%

2.0%

3.0%

4.0%

Perc

ent

0.0%CY

2003CY

2004CY

2005CY

2006FY

2008FY

2009FY

2010FY

2011FY

2012FY

2013FY

2014FY

2015FY

2016YearData Updated: 2/20/16

Source: (CY's: BMT Admin) (FY 2008-2016: ICU Utilization Tool)

0.0%

1.0%

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

YearData Updated: 2/20/17Source: (CY's: BMT Admin) (FY 2008-2016: ICU Utilization Tool)


( ) ( )

Stanford’s ICU Utilization Rate

I 2013 U it d H lth C ti (UHC)In 2013, United Healthcare Consortium (UHC) ICU utilization rate for HCT recipients was 29.6%

Stanford is ~ 5%


Results

BMT ICU Discharge Disposition

25

40

25

35

24

29

40

24

30

25

30

35

40

45

f Pat

ient

s

FY 2008

9

4

17

6

11

2

16

610

5

17

5

16

58

00 05

10

15

20

5

Num

ber o

f FY 2008

FY 2009

FY 2010

FY 2011

FY 2012

FY 20130

D/C to E1 Deceased in ICU Deceased on E1

Disposition

FY 2013

FY 2014

FY 2015

FY 2016Data Updated: 2/20/17Source: ICU Utilization Tool)


ICU BMT mortality rate decreased to 33%

ICU Mortality H it l t lit f ti t i i h i l til ti d Hospital mortality for patients requiring mechanical ventilation and

vasopressor support was 71%

Patients not requiring mechanical ventilation and vasopressor support was 24% (p< .0005).

A BMT comorbidity index (HCT-CI) was available for 71.3% of the patients.

−No significant difference between low index (0-3) score and high index (4-8) score

−Comorbidity did not effect ICU outcomes


Comorbidity did not effect ICU outcomes

25

Strongest Predicter of Mortality Aft dj ti f ll i bl ( dAfter adjusting for all variables (age, gender, race,

product, preparative regimen, donor, GVHD, h i l til ti d/ )mechanical ventilation and/or vasopressor)

−Only 2 variables were significantly associated with y g ymortality

Age >55 yearsAge >55 years

Combination of mechanical ventilation with


vasopressor support 26

Length of Stay (LOS)

Significant relationship between LOS and deathSignificant relationship between LOS and death.

−Patients with ICU LOS <5 days had a mortality of 33%

−Patients with ICU LOS >10 days had a mortality ofPatients with ICU LOS >10 days had a mortality of 74%


Project Benefits

Appropriate admission of BMT patients into the ICU based on criteria from recent literature and probability of survival

Appropriate utilization of ICU beds for BMT patients which results in better resource utilization and avoiding futile, costly care

Consistent rounding between BMT and ICU facilitates communication among physicians, the care teams involved, and with the family

Consistent communication ensures accurate information to patients and families enabling them to make educated decisions regarding care

Increased satisfaction for patients families and staff


Increased satisfaction for patients, families and staff

SummaryDATADATA

Clear Communication

−Critical for making informed decisions

−Essential for managing valuable resources

−and the appropriate Utilization of the ICU


CURRENT /ONGOING PROJECTS

R t ti l f 400 d d ll ti t l t 7 t Retrospective eval of 400 deceased allo patients over last 7 years to evaluate presence or absence of AD and relationship of AD to ICU utilization, end of life healthcare utilization, and location of death

Retrospective eval of acute leukemia patients relapsing after allo to evaluate health care utilization at relapsee a ua e ea ca e u a o a e apse

Patient/Proxy study using Stanford Letter to determine if patient EOL wishes and caregiver’s perception of patients EOL wishes matchwishes and caregiver s perception of patients EOL wishes match.

randomized controlled trial of Stanford Letter vs standard AD in allotransplant patients


transplant patients

30

BMT Physicians are using cutting edge technologies andBMT Physicians are using cutting edge technologies and clinical trials to advance the science of transplantation and improve cure rates creating a culture that can focus on the p gpotential for cure despite obvious suffering

Roland E et al, Journal of Supportive Oncology, May –June 2010: 8:100-116

Palliative care is best practice for patients with a serious illness to help relieve their symptoms and psychological distress.

It is recommended that Palliative Care be delivered with in the


continuum of care for HCT patients

31

Collaborating with Palliative Care- future ideas

Consistent Palliative Care APP who rounds with BMT & develops relationship with both BMT team & patientswith both BMT team & patients

Requiring Advanced Directive (or Letter) for all BMT patient coming to Transplant.p

All High Risk BMT patient get an automatic referral to Palliative Care- need triggers

Others?


Documents

Bl d d M T l tBlood and Marrow Transplant ICU Utilization ...cmesyllabus.com/wp-content/uploads/2017/03/Day-2-Updated-Presentation-Jenkins-Trisha.pdfSource: (CY's: BMT Admin) (FY 2008-2016: