NICU Length of Stay Initiative: Lessons Learned

NICU Length of Stay Initiative:Lessons Learned

Rick McClead MD MHA

Professor and Vice-chairman

Department of Pediatrics

Division of Neonatology

In the beginning….I have this

great idea!

C.O.P.E. can

lower LOS in

the NICU by 8

days! I only

need $10K!

What’s your

idea?

Dr. McClead,

Make it

happen!

You gotta be $#!^ing me!

(Spring 2009)Dr. Brilli,

Make it

happen!

Benefits of COPECost Savings / Decreased Length of NICU Stay for Infants

4 day shorter length of NICU stay for preterms 26-34 weeks 8 day shorter length of NICU stay for preterms under 32 week

Improved Parent Outcomes Less stress in the NICU Stronger beliefs/confidence in their ability to care for their perterm infants More developmentally sensitive interactions with their preterm infants Less depression and anxiety symptoms during and after NICU stay

Greater satisfaction with the NICU stay Higher readiness for their infant's discharge from the NICU

Evidence-Based Educational-Behavioral Program

How can I reduce NICU LOS with only one intervention?

You Can’t!

Lesson # 1

• You must understand your data!

• What does you population look like?

• What factors contribute to long length of stay, and which factors can you impact?

• What is a long length of stay?

• Where are the data to answer these questions?

Two Populations Contribute to LOS

What is a long LOS?What are the contributing factors to a long LOS?

What is the Average LOS?

Why are infants hospitalized longer than 37 weeks CGA?

Not Statistically Significant VON DataAdmit by DOL 3 or DOL 7RaceHispanic ethnicityNo PNCDelivery ModeMultiple GestationHFVRDSSteroids for BPDIndocin therapy for PDANECNEC SurgeryPVLFungal SepsisLate Bacterial SepsisIVHHome O2/monitor

Statistically Significant* VON DataLower EGAInbornNo Antenatal SteroidsMale GenderPDAPDA LigationSevere ROP/ ROP SurgeryOther SurgeryPneumothoraxGI PerforationCongenital Malformation (Gastroschisis)CONS SepsisOxygen at 36 weeks CGANAS

* Items in red could be influenced by QI team

Where do we start?

Start with engaged staff!

Lesson # 2

• Start with something that already is of interest to the staff, and has a physician and nurse champion!

• COPE

• Neonatal Abstinence Syndrome

• Gastroschisis

• Feeding failure

• Palliative Care

How do I organize the QI work?

Decide on a QI methodology

Lesson # 3

• Choose a QI infrastructure!

• Model for Improvement

• Six-sigma/Lean

• Toyota Production System

• FOCUS-PDSA

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale

Tests of Change

Implementation

of Change

PDSA Cycles for TestingWhy Test?

• Increase your belief that the change will result in improvement

• Document how much improvement can be expected from the change

• Learn how to adapt the change to conditions in the local environment

• Evaluate costs and side-effects of the change

• Minimize resistance upon implementation

Lesson # 3

• Choose a QI infrastructure!

• Model for Improvement

• Six-sigma/Lean

• Toyota Production System

• FOCUS-PDSA

• Create a specific SMART aim and a key driver diagram

Specif ic

___What is the goal or intent. Precisely and concisely describe what is to be achieved. It MUST focus on achieving only ONE thing.

Measurable

___There is a direct relation between the increase and the decrease of a measure and the attainment or loss of the goal. Recommend: Start the Aim Statement with Increase/Decrease…then describe the object of what is to be measured

___There are means with which to measure and monitor progress over time (to take, collect, and record the measurement)

Actionable

___The team can take action to overcome any known barriers to achieving the proposed measurable results

___The ‘HOW’ of achieving this goal in NOT part of the Aim Statement (this would restrict other plausible solutions)

Realistic

___Given the resources available, it is within the teams ability to achieve, control, or influence the Aim’s attainment

___There is no significant that will compete with the time, attention or ability to achieve the goal

Timely

___The goal has a target date. If timeline is beyond 6 months there are interim Milestones. Recommend: …achieve intent by a specified date ___There is nothing that should compete with the time and attention

needed to achieve the goal

Worksheet for Creating a SMART Aim Statement

Key Driver Diagram

• This Learning Structure helps everyone on the team from the physician to the housekeeper understand the approaches, recommendations, and processes that have to be followed to reach the goal.

• The diagram identifies and spells out acceptable practice for providing care and creates a common language that everyone is expected to follow.

• Without these interventions, you are less likely to achieve the goal.

• To the left of the key drivers are the components of “how” you will get there.

• Using a diagram like this as a visual can help to focus staff and management on the important and necessary things for reaching a positive outcome.

• http://www.stanleyhealthcare.com/sites/www.stanleyhealthcare.com/files/pdf/Aug08.pdf

Global Aim & Key Drivers

Reduce ALOS for all infantsadmitted to Main Campus Neonatal Services from a baseline* of 42.4 days to 28.4 days by Sept 30, 2010.

Key Drivers

Design Changes/Interventions

Global Specific Aim

Team Communication

Care of ELBW Infants

Care of NAS patient

Care of Gastroschisis

Weekly meetingsMonthly meetingsQI Companion

Establish small baby teamDevelop sub-aim with KDD &

interventions

Establish NAS QI TeamDevelop KDD with interventions

Establish Gastroschisis TeamDevelop sub-aim with KDD &

interventions

* Average LOS from Jan-Sept 2009

Balancing measures

Mortality rate

Readmission rate

ED visit rate

Care of lethal anomaly Engage palliative care groupDevelop sub-aim with KDD &

interventions

Aim & Key Drivers for SBP

Reduce ALOS for infants < 27Weeks EGA admitted to Main Campus Neonatal Services from a baseline* of 95.5 days To 90.5 days by December 31, 2010.

Key Drivers

Design Changes/Interventions

Specific Strategic AimQI Team Communication

Parent Empowerment

Severity of illness on admission

Feeding Failure

Weekly meetingsMonthly meetingsQI Companion

Implement C.O.P.E. in SBPP.E.E.P. all main campus unitsParent education complete before DOD

Eliminate hypothermia (done)Standardize management of the PDA(MCSA and RMH)-doneMinimize surgical ligation

Establish Feeding Failure Team-6/10Standardize feeding regimen-Conduct weekly feeding rounds-6/10Monitor feeding milestonesSpread to C4 from J4- in progress

* Average LOS from Jan-Sept 2009

Balancing measures

Mortality rate

Readmission rate

ED visit rate

Inadequate nursing documentation

Survey doctors for expectationsStandardize Nursing documentation

That is great, but how do I know when I have actually improved?

Look at your data

Lesson # 4• Use charts and graphs to visualize your data

Run Chart Frequency Plot

Waiting Time for Clinic Visit

20

25

30

35

40

45

50

55

60

Avera

ge D

ays

Distribution of Wait Times

0

10

20

30

40

50

60

5 15 25 35 45 55 65 75 85 95 105

Wait time (days) for Visit

nu

mb

er

of

vis

its

Pareto ChartScatterplot

Lesson # 4

• Use charts and graphs to visualize your data

• Understand variability using annotated statistical process control charting

• Improved Visibility into Process & Outcomes• What kinds of problems are most prominent?

• How is our performance changing over time?

• What impact have our actions or interventions had?

All Processes Vary!

Common Cause Variation

Unavoidable variation inherent in the system. This will affect numbers of

medication errors, falls, BSIs, etc. (within limited ranges). The amount of variation depends upon the system’s current characteristics, but a certain amount will always exist.

The point-to-point ups and downs in common cause variation are RANDOM.

They do not have particular causes. Looking for cause is generally futile. And attributing a cause, however tempting that may be, is risky at best and can lead to misdirected efforts.

Common cause variation on a control chart is what generally appears between the control limits (with the exception of certain “special cause” patterns).

All Processes Vary!

Special Cause Variation

Variation that is not an inherent part of the system or process. It will generally

arise from specific circumstances. Examples of potential special causes are:

Faulty Materials or Equipment

Unusually High/Low Patient Volume or increase/decrease in the

proportion of high-risk patients.

Unusual Staff Shortage

Sudden Influx of New Staff

Non-standardized practices (e.g., differences across shifts).

Special cause is indicated on a control chart by points outside the control limits or by certain patterns, for which we have several “rules of thumb” for recognizing.

When do you have special cause variation?

1 data point > 3 δ from centerline

9 point in a row, above or below centerline

6 points in a row, all increasing or decreasing

2 of 3 points > 2 δ from center line

15 points in a row within 1 δ of centerline

Specific Aim: Reduce ALOS for infants < 27 Weeks EGA admitted to Main Campus Neonatal Services

from a baseline* of 95.5 days To 90.5 days by December 31, 2010

Apr-2011Jan-2011Oct-2010Jul-2010Apr-2010Jan-2010Oct-2009Jul-2009Apr-2009Jan-2009

300

150

0

DCMoYr

Sample Mean

__X=95.5

UCL=151.4

LCL=39.5


150

100

50

0

DCMoYr

Sample StDev

_S=63.1

UCL=104.0

LCL=22.3

2

1

Xbar-S Chart of Main Campus Initial Length of Stay<= 27 Gestational Weeks - Jan 2009 to Date

Historical Mean and Control Limits from Jan-Aug 2009

Ave LOS 101 66 110.3 120 79.7 7.6 75.2 108.3 88.5 56.3 6.0 94 114.3 99.7 144.8 123.1 97.6 68 78.9 97.9 80.1 81.0 91.3 84.9 89.1 57.5 72.7 47.8D/C N = 10 4 10 19 13 9 11 10 14 8 1 17 14 12 11 15 9 5 11 6 13 11 12 12 13 14 7 12

SpecialCause Variation(9 points at or below centerline)

Lesson # 4


• Understand variability using annotated statistical process control charting.

• When you find special cause variation, investigate its cause.

0

50

100

150

200

250

300

350

400

450

500

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

Da

ys

Patients

SBP LOS 12/08/08-10/26/10 Survivors

De

c 0

8 (P

atie

nt 1

)

Ju

n 0

9 (P

atie

nt 9

)

Se

pt 0

9 (P

atie

nt 2

0)

De

c 0

9 (P

atie

nt 4

4)

Dates of Admission

COPE Starts

COPE Planning

Impact of COPE/PEEP on Neonates admitted to Small Baby Pod

COPE Training

No

v 0

9(P

atie

nt 3

6)

Ap

r 10

(Patie

nt 5

4)

Ju

n 1

0 (P

atie

nt 6

8)

PEEP Discharge Teaching

Feeding Runds

PEEP RN Documentation

Se

pt 1

0 (P

atie

nt 7

6)

Oc

t 10

(Patie

nt 8

1)

Ma

r 20

11

(Patie

nt 9

2)

Impact of Feeding Program on LOS for infants < 32 weeks PMA without Surgical Problems of Congenital Anomalies

Specific Aim: Reduce ALOS for all infants admitted to Main Campus Neonatal Services from a baseline of 42.4 days to 28.4 days by Sept 30, 2011.


60

40

20

DCMoYr

Sample Mean

__X=42.47

UCL=62.26

LCL=22.67


60

50

40

30

DCMoYr

Sample StDev

_S=50.04

UCL=64.13

LCL=35.95

6

6

11

11

1

1

1

1

Xbar-S Chart of Main Campus Initial Length of StayAll Gestational Weeks - Jan 2009 to Date

Historical Mean and Control Limits from Jan-Aug 2009

Ave LOS 44.6 34.9 48.4 51.0 41.2 33.9 36.7 47.4 39.0 29.0 31.8 41.9 43.9 46.3 45.9 44.2 42.6 28.3 34.3 35.2 34.3 29.3 45.3 37.3 44.7 29.3 30.6 28.1

D/C N = 52 53 56 75 66 66 65 70 75 69 79 49 70 59 62 67 81 60 73 75 69 69 54 73 55 56 61 58


0.20

0.15

0.10

0.05

0.00

MoYr

Proportion

_P=0.0694

UCL=0.1694

LCL=0

P Chart of All Deaths

Tests performed with unequal sample sizes

Balancing Measure for Specific Aim: Reduce ALOS for all infants admitted to Main Campus Neonatal Services from a baseline of 42.4 days to 28.4 days by Sept 30, 2011.

D/C N = 52 53 56 75 6 66 65 70 75 69 79 49 70 59 62 67 81 60 73 75 63 69 54 73 55 56 61 58

Montly Discharges from the NCH NICU (Jan 2009-April 2011)

0

10

20

30

40

50

60

70

80

90

100

J09 F M A M J J A S O N D J10 F M A M J J A S O N D J11

Month

Nu

mb

er

of

Pa

tie

nts

APR-DRG Mortality Risk for Neonates admitted to Main Campus Neonatal Services

Sep10Jul10May10Mar10Jan10Nov09Sep09Jul09May09Mar09Jan09

1.65

1.50

1.35

1.20

Discharge Month

Sample Mean

__X=1.4755

UCL=1.6522

LCL=1.2988

Sep10Jul10May10Mar10Jan10Nov09Sep09Jul09May09Mar09Jan09

1.0

0.9

0.8

0.7

Month-Yr

Sample StDev

_S=0.8279

UCL=0.9531

LCL=0.7027

1


Xbar-S Chart of Risk of Mortality

Lesson # 4


• Understand variability using annotated statistical process control charting.

• When you find special cause variation, investigate its cause.

• Track a balancing measure to make sure something untoward is not happening.

More on Lesson # 4

Use the right control chart to track your data

Nov-2010

Sep-2010

Jul-2010

May-2010

Mar-2010

Jan-2010

Nov-2009

Sep-2009

Jul-2009

May-2009

Mar-2009

Jan-2009

0.06

0.05

0.04

0.03

0.02

0.01

0.00

DCMoYr

Proportion

_P=0.00926

UCL=0.05162

LCL=0

P Chart of Mortality at RMH


Mortality for all infants admitted to the NICU at RMH

Mortality for all infants admitted to the NICU at RMH

111098765432

300

250

200

150

100

50

0

Observation

Days Between Events

LCL= 0.000

UCL=282.695

CL= 70.300

G Chart of RMH Deaths

Lesson # 5

• When you find something that works to improve a process, spread the learning to another area!

Aim & Key Drivers for NAS

Reduce LOS of main campus NAS patientsfrom 31 to 24 days

by December 31, 2010

Specific AimNursing Assessment

Nursing Documentation

Weaning Protocol

Maternal Management

Education re patient assessment and scoring

Compliance Monitoring

Develop alternative Weaning protocol

Collaborate with OBGYNs

Key Drivers

Design Changes / Interventions

0

50

100

150

200

250

Mar April May JuneAugust Sept Oct NovDec Jan Feb Mar April MayJun JulyAugust Oct Nov Jan Feb Mar

LO

S (

Da

ys

)

Date

NAS Patients Discharged from Main Campus NICUs 3/2/09-7/12/10

X chart

LOS Data for Main Campus NAS Patients

Methadone Weaning Protocol

NAS Task Force

Convened

Morphine weaning protocol

24.1 days

Failed Morphine weaning

30.94 days

58 days

IUGR infant required only 6

days of morphine but prolonged W/U for hypoglycemia Surgical infant

required opioid for pain control; began

weaning DOL13

Specific Aim: Reduce LOS of main campus NAS patients from 24.1 to 18 days by Sept 30, 2011

Infant with CHD

0

20

40

60

80

100

120

140

160

180

200

Oct Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan'2011Feb Mar Apr

LO

S (

Day

s)

Date

NAS Patients Discharged from GMC October 2009-January 2011

Morphine Protocol

Methadone Protocol

20102009

Black circle = Methadone wean

Blue triangle = Morphine wean

LOS Data for GMC NAS Patients

2011

Lesson # 6

• Be careful of “before” and “after” comparison

Aim & Key Drivers for Gastroschisis

Reduce LOS of uncomplicated Gastroschisis patients from

44 to 34 days by Sept 30, 2010

Specific AimGuideline

Feeding Delays

Discharge Preparation

Revise GuidelineObtain surgical supportMonitor guideline use& explainVariancesSurgical attending round 2x/wk

Develop Feeding Plan per Jadcherla et al

Develop & Implement Parent Road Map(Similar to COPE & PEEP)

Key Drivers


Pain ManagementStandardized post-op protocolImplement protocol

0

20

40

60

80

100

120

Jan Feb MarApril MayJul AugSept Oct DecJanMar AprilJulAug Sept OctNov Dec Feb

Le

ng

th o

f S

tay

(D

ay

s)

Patients

LOS of Uncomplicated Gastroschisis Patients 1/2009-12/2010

43.8 days

BG Reeder: Silo

Feeding intolerance

Cholestasis, Malro

BB Hayes: Silo

Feeding intolerance

Cholestasis

New Protocol

Specific Aim: Reduce LOS of uncomplicated* Gastroschisis patients from 44 to 34 days by Sept 30, 2011

* Excludes premature infants < 34 weeks PMA and any infant with multiple surgeries (e.g. stenosis or atresia repairs)

Good

33.7 days

0

20

40

60

80

100

120

Jan Feb MarApril MayJul AugSept Oct DecJanMar AprilJulAug Sept OctNov Dec Feb Mar

Le

ng

th o

f S

tay

(D

ay

s)

Patients

LOS of Uncomplicated Gastroschisis Patients 1/2009-12/2010

43.8 days

BG Reeder: Silo

Feeding intolerance

Cholestasis, Malro

BB Hayes: Silo

Feeding intolerance

Cholestasis

New Protocol

Specific Aim: Reduce LOS of uncomplicated* Gastroschisis patients from 44 to 34 days by Sept 30, 2011

* Excludes premature infants < 34 weeks PMA and any infant with multiple surgeries (e.g. stenosis or atresia repairs)

Good

Lesson # 7

• When you introduce a “test of change,” monitor compliance.

Gastroschisis Timeline ReviewFirst Infant on Protocol

LOS=

44 days

Gastroschisis Review

Lesson # 8• Track the performance of the teams

1.0 Team has been formed; target population identified; baseline measurement begun.

1.5 Team is meeting, discussion is occurring. Plans for the project have been made.

2.0 Team actively engaged in development and discussion, but no changes have been tested.

2.5 Components of Change Package being tested but no improvement in measures. Data on measures are being reported.

3.0 Initial test cycles have been completed and implementation begun for several components. Evidence of moderate improvement in process measures.

3.5 Some improvement in outcome measures, process measures continuing to improve, PDSA cycles on multiple components of the Change Package.

4.0 Evidence of sustained improvement in outcome measures, halfway toward accomplishing all of the goals. Plans for spreading the improvements are in place.

4.5 Sustained improvement in outcome measures, 75% of goals achieved, spread to a larger population has begun.

5.0 Major change in all areas of the Change Package has occurred, all goals of the AIM have been accomplished, outcome measures at national benchmark levels, and spread to another department is underway.

Lesson # 9

• For big QI projects, you need senior leadership on board.

NICU LOS Reduction ProjectResults to Date

1. Overall ALOS for main campus NICU has decreased 7 days from 42 to 35 days

2. ALOS for infants < 27 weeks EGA admitted to main campus NICU has decreased 10 days from 95-85 days.

3. ALOS for main campus NAS patient has decreased 7 days from 31 to 24 days. ALOS for NAS patients at offsite nurseries has decreased to < 20 days.

4. ALOS for infants with uncomplicated gastroschisis has decreased ~ 9 days from 44 to 35 days.

5. Over 4,000 unnecessary patient days have been avoided since June 2010.

6. The estimated financial impact of the project to date is in excess of $6,000,000.

Aim & Key Drivers for Intestinal Injury

Reduce the incidence of NEC in infants

< 1500 g Birth weight from 7.4% to 3.8%* by

December 31,2012

Strategic AimFeeding Protocol

Transfusion Policy

Restrict feeds

Engagement by referring Hospital NICU/SCNs

Feed according to protocolFeed mothers own milk or

Donor breast milk exclusivelyPerform oral care with EBM

Avoid routine transfusions for Hb > 7 g/dL

Hold feeds during transfusion

Meet with medical directors of allReferring NICU/SCNs to obtain

Agreement to feeding protocol and Transfusion guidelines

Key Drivers


* NEC @ NCH, 7.4%

CHCA Lower quartile, 3.8%

Documents

NICU Length of Stay Initiative: Lessons Learned