Resuscitation and Early Intervention · • Resuscitation can be the low hanging fruit of reducing hospital mortality. • Done right, you can effectively reduce the raw mortality

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Resuscitation and Early Intervention

October 25, 2019

T. Mike Truxillo MD

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Why Resuscitation?

3October 24, 2019

• Resuscitation can be the low hanging fruit of reducing hospital mortality.

• Done right, you can effectively reduce the raw mortality of your hospital rather quickly

• Added bonus is that these events can be some of your highest profile, highest liability mortalities for the hospital

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Resuscitation is a Great Place to Start

There are only a few common ways that patients die in a hospital

• Clinicians and systems need to identify patients earlier and distinguish between acute physiologic deterioration and signs of chronic disease.

• Patients are often admitted to hospital with an acute condition and an unrelated or a number of unrelated long-term conditions:

• for example pneumonia with a background of chronic heart and/or chronic renal failure;

• Recognizing and preventing acute deterioration whether it's from an acute or chronic disease process is what keeps your patient safe

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The Clinical Challenge is Recognition

Acute vs chronic disease in deterioration

Failure to Rescue Physiologic Deterioration:

Earlier recognition = better results

TIME

A Healthy Patient

85% Mortality

25% Mortality

Code Blue

Reactive Rapid

Response

Proactive Intervention

We have to identify our high-risk patients earlier

Unrecognized clinical deterioration

Attitude of response team upon arrival

Fear of triggering hospital-wide systems

Emotional distress in activating RRS unnecessarily

Staffing

Normalization of Deviance

Barriers to initiation of the Rapid Response SystemWhat keeps your bedside providers from identifying these patients and escalating concerns

Commonly published outcome measures for RRS include:

• decreased rates of cardiac arrests outside ICU

• reduced unplanned transfers into ICU.

Solution: Rapid Response Systems (RRS)

RRS have been promoted as a safety intervention for patient’s experiencing clinical deterioration.

• Expert clinical support provided by Early Intervention teams to novice staff

• Prevention of adverse events

• Quality improvement opportunities discovered by Early Intervention teams.

Rapid Response Systems (Early Intervention)

Less commonly published outcomes of Rapid Response Systems include

10October 24, 2019

What Did Our Journey Look Like?

Our 2017 Baseline Rapid Response System (RRS)

1 Critical Care Nurse Assigned

each day to Rapid Response Calls

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The Problem With That System

Increasing patient acuity in a system not designed to meet the challenge

Predicted Rate of Emergencies (without intervention)

• Proactive Rounding on high risk patients

• Pre-code work / prevention

• Facilitating transfers

• Engaging and teaching our floor nurses

• Team training for reproducible responses

• Collecting accurate data to improve our processes

• Putting our staff in a position for them to be successful

• Spreading a culture of safety – every mortality matters.

What Were We Not Doing?

A Lot of Best Practices

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A Framework For Improvement

Build the Structure

Improve your Process

Track your Outcomes

Share Findings with partners

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IHI PDSA Cycles

Quality Improvement 101

15October 24, 2019

The First Step

PDSA Staff Cycle #1: September 2017

Critical Care Nurse Assigned


Deterioration iOAlerts to activate Critical Care APPs

86%

• Sending alerts to Critical Care APPs Mon-Fri 9a-4p• Alert threshold set to only send on average 3 alerts/day• Monday’s threshold is higher due to more people at risk • Model specificity improves with each model update• Per APPs: Quite predictive of patients at risk of decline• The specificity has improved leading to greater ability to

monitor, intervene or change code status.

Improve Early Recognition

Ochsner model uses recurrent neural networks

This model architecture has internal memory units that can identify patterns over time

Think self-driving cars: they know where they’ve been and where they're going

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Deep Learning & Recurrent Neural Networks

The neural network provides greater sensitivity and specificity than traditional risk models

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The Next Step

PDSA Staff Cycle #2: December 2017

Critical Care Nurse Assigned each day to Rapid Response

Calls

IO Deterioration Alert

Proactive Rapid Response Nurse

24/7

Added Dedicated Rapid Response Nurse and Proactive Rounds

Nurses helping Nurses model of support

Operations & Workflow

Technology Based Risk Stratification

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How Did that First Year Go?

October 24, 2019

Metrics

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Transfers to ICU after a Rapid Response

Benchmark- Get With The Guidelines Resuscitation (Academic Hospitals)

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Percent Not Transferred to ICU after Rapid Response Consult

Benchmark- Get With The Guidelines Resuscitation (Academic Hospitals)

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Outcomes:

Overall – Jeff Hwy

RAMI = 0.94Obs Mort = 633/23,940 (2.6%)

Lives Saved = 39.4

Proactive RRT Calls

RAMI = 1.05Obs Mort = 107/1,868 (5.7%)

Lives Saved = -5.0

Reactive RRT Calls

RAMI = 2.12Obs Mort = 248/737 (33.6%)

Lives Saved = -130.9

All Other Patients

RAMI = 0.61Obs Mort = 278/21,335 (33.6%)

Lives Saved = 175.3

Code

RAMI = 1.38Obs Mort =

8/21 (38.1%)Lives Saved = -2.2

No Code


99/1,847 (5.4%)Lives Saved = -2.8

No Code


73/480 (15.2%)Lives Saved = -27.5

Code


175/257 (68.1%)Lives Saved=-103.5

Response Team Impact to OMC RAMI

Methodology:1) The final event associated with the HAR – based on if it’s

proactive or reactive ties it to the respective bucket.2) Following notes are used to tie a HAR to ‘Coded’

a. ('Code Start', 'Code End',

'RRSCODEBLUE')

3) ICU data is for only HARs that were intervened by Rapid Response Team. Proactive or reactive

4) RNconsult which is reactive is left as it’s own separate category for the time being due to low volume

2018 CY

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How Can We Improve in 2019?

October 24, 2019

Prevent Unexpected

Mortality

•Proactively prevent failure to rescue on in-patient floors

•Enhance early recognition of patient deterioration through staff training

•Leverage technology for surveillance

Optimize Care Effectiveness

•Improve compliance with care bundles

•Provide timely & meaningful feedback

•Use evidence- based care guidelinesEnhance Staff Engagement &

Patient Experience

•Improve communication within units and between units

•Provide support to patients and families

Provide High Quality

Resuscitation

•Train staff in difficult conversations

•Encourage Early Palliative care

•Provide high quality end-of life care

World Class Rapid Response

System

Aim Primary Drivers Secondary Drivers

Recognize Medical Futility

•Utilize AHA compliant equipment

• Simulation and In situ staff training

High Reliability Organization

Rapid Response System Driver Diagram

#1

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The Adherence to Protocols Improves Outcomes

Resuscitation. 2013;85:82-87




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The Next Step

PDSA Staff Cycle #3: January 2019


Calls



24/7Ochsner ACLS

Started with Inter-professional Training

PDSA Cycle #3

• Capital Request for replacement of defibrillator fleet

• Enhanced monitoring

• Code cart revision

• Emergency stretchers

• Optimization of communication systems

Standardized the Tools

Equipment and Supplies Taskforce

A Resuscitation Report Card

First Steps: Version 1.0

A qualitative analysis was performed of data from semi structured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines–Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019.

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How Do You Structure Your System?

How do rapid response teams differ between top-performing and non–top-performing hospitals for resuscitation care?

Differences in RRTs at top-performing and non–top-performing sites were found in the following 4 domains:

1. team design and composition,

2. RRT engagement in surveillance of at-risk patients,

3. empowerment of bedside nurses to activate the RRT, and

4. collaboration with bedside nurses during and after a rapid response.

At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff.

40October 24, 2019

How Do You Structure Your System?

How do rapid response teams differ between top-performing and non–top-performing hospitals for resuscitation care?

41October 24, 2019

Prevention is THE Key Activity

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The Next Step

PDSA Staff Cycle #4: January 2019


Calls



24/7Ochsner ACLS

Proactive RRRN + 2nd RRRN to Day

Shift

October 24, 2019 43

44October 24, 2019

Higher Mortality Rate Persists Over Time

2019 Floor Code Calendar

24 of our 30 Arrests occurred during nights, weekends, holiday and handoffs

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The Next Step

PDSA Staff Cycle #5: July 2019


Calls



24/7Ochsner ACLS

2 proactive RRRNs 24/7

Total Floor Codes 2018: 87

Lets address our largest cause of codes directly

Respiratory Events: 27

Cardiac-General: 22

Aspirations: 12

Arrhythmias: 8

Bathroom-Vagal 4

Renal-HD 3

Pulmonary HTN 3

Stroke 3

GI Bleed 2

Sepsis 1

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The Next Step

PDSA Staff Cycle #6: Added a Proactive Respiratory Therapist to Day Shift

Critical Care Nurse Assigned




24/7Ochsner ACLS

2 proactive RRRNs 24/7

1 Proactive Respiratory

Therapist day shift

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Prevention is THE Key Activity

Planned vs Unplanned Transfers

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Building a Durable Structure To Support the Work

Resuscitation Data

Goal- Automation

Need 100% Epic documentation for automation

Daily actionable reports

Standardized reporting

Decreased manual work

Provide calculations for “lives saved”

Documentation Adherence Rate

# documented events in Epic/total events (eg. on paper)

• OMC 2015=20% to 2019=99% compliance

• Other facilities approx. 20-70% compliance

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Infrastructure

Weekly Code Review Process

Rapid Cycle Feedback

Floor Date of last CPA Todays date Days since last CPACSU 6/29/2019 7/10/2019 11

CTSU 3/10/2019 7/10/2019 122

POSS 4/3/2019 7/10/2019 98

MSU 4/20/2019 7/10/2019 81

MSU "W" 6/11/2019 7/10/2019 29

NSU 5/20/2019 7/10/2019 51

NSU"W" 4/20/2019 7/10/2019 81

ONC 5/11/2019 7/10/2019 60

GISSU 4/21/2019 7/10/2019 80

MTSU 6/6/2019 7/10/2019 34

TSU 5/3/2019 7/10/2019 68

IMTA 2/13/2019 7/10/2019 147

OBS1 Do not have data 7/10/2019 #VALUE!

OBS3 Floor opened in 2019 7/10/2019 #VALUE!

Overall – Jeff Hwy

RAMI = 0.97Obs Mort = 407/15,647 (2.6%)

Lives Saved = 11.7

Proactive RRT Calls

RAMI = 0.88Obs Mort = 89/2,237 (4.0%)

Lives Saved = 11.7

Reactive RRT Calls

RAMI = 1.92Obs Mort = 139/422 (32.9%)

Lives Saved = -66.5

All Other Patients

RAMI = 0.73Obs Mort = 179/12,988 (1.4%)

Lives Saved = 66.5

Code


7/27 (25.9%)Lives Saved = -1.6

No Code


82/2,210 (3.7%)Lives Saved = 13.2

No Code


31/254 (12.2%)Lives Saved = -13.1

Code


108/168 (64.8%)Lives Saved=-53.5


Methodology:1) The final event associated with the HAR – based on if it’s

proactive or reactive ties it to the respective bucket.2) Following notes are used to tie a HAR to ‘Coded’

a. ('Code Start', 'Code End',

'RRSCODEBLUE')



2019 August YTD

Proactive

Proactive

Total Reactive

Reactive

Total

All Other

Pts

All Other

Pts Total Grand Total

Years Values No Code Code No Code Code No Code

2018 Average of icu_los 7.32 11.17 7.41 7.53 11.06 8.83 8.00

Volume (Qual) 1,847 21 1,868 480 257 737 21,335 21,335 23,940

Obs Morts (Qual) 99 8 107 73 175 248 278 278 633

Obs_Mort_Rate 5.4% 38.1% 5.7% 15.2% 68.1% 33.6% 1.3% 1.3% 2.6%

RAMI 1.03 1.38 1.05 1.60 2.45 2.12 0.61 0.61 0.94

Lives Saved -2.8 -2.2 -5.0 -27.5 -103.5 -130.9 175.3 175.3 39.4

2019 (Aug YTD) Average of icu_los 7.96 28.81 8.51 9.09 9.96 9.49 3.76 3.76 8.64

Volume (Qual) 2,210 27 2,237 254 168 422 12,988 12,988 15,647

Obs Morts (Qual) 82 7 89 31 108 139 179 179 407

Obs_Mort_Rate 3.7% 25.9% 4.0% 12.2% 64.3% 32.9% 1.4% 1.4% 2.6%

RAMI 0.86 1.29 0.88 1.73 1.98 1.92 0.73 0.73 0.97

Lives Saved 13.2 -1.6 11.7 -13.1 -53.5 -66.5 66.5 66.5 11.7


Methodology:1) The final event associated with the HAR – based on if it’s proactive or reactive ties it to

the respective bucket.2) Following notes are used to tie a HAR to ‘Coded’

a. ('Code Start', 'Code End', 'RRSCODEBLUE')



ICU and Non-ICU Cardio-Pulmonary Arrests

Non-ICU Cardio-Pulmonary Arrests and Rapid Response Consults2006 to 2019

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What’s Next?

October 24, 2019

60October 24, 2019

61October 24, 2019

• AHA Get With the Guidelines Gold Certification.

• Our stroke program has had gold certification and is a model of what we would like to achieve with our program

Goal: National Leader in Resuscitation

Robust internal metrics drive success

Education

• Artificial Intelligence for

Recognition of Deterioration

• Wired Rooms and Tele-Medicine

• Wireless Monitoring (ViSi) of

Patients for continuous data.

Care Team Coordination• Rapid Response

• Code Blue

• Stroke Code

• Inpatient Code STEMI

• Pulmonary Embolism (PERT)

Staffing

• Create Rapid Response Service Line

• Add MD/APP to lead service

• Flexible staffing model with ICUs

Smart Systems

Continue to build Ochsner ACLS /

Prevention

Research / Reputation• Publication of outcomes to drive

national recognition.

Patient Satisfaction• Organized / Timely response,

drives patient satisfaction

• Patient / Family activated Rapid

Response

Think about Resuscitation as a Service Line

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Questions?

October 24, 2019

Non-ICU Cardio-Pulmonary Arrests

A Resuscitation Report CardHopkins Version 3.0

A Resuscitation Report CardFirst Steps

ICU and Non-ICU Cardio-Pulmonary Arrests

• Recommendation #1: Hospitals should measure and track cardiac arrests in regular ward patients

• Recommendation #2: hospitals should measure predictable cardiac arrests in general ward patients

• Recommendation #3: hospitals should measure timeliness of their response to ward patient deterioration

• Recommendation #4: hospitals should evaluate timeliness of critical care interventions

• Recommendation #5: patients that exhibit warning signs should receive timely documentation of goals of care.

• Recommendation #6 hospitals should provide means by which patients and family members can activate the rapid response team.

• Recommendation #7: hospitals should consider measuring the frequency of RRT activations generated by patients and family members

• Recommendation #8: hospitals should evaluate safety culture in relation to deteriorating patients and their care

• Recommendation #9: hospital should measure the length of stay on general wards of all patients with a breach of escalation criteria.

• Recommendation #10: hospitals should measure ICU length of stay of patients transferred to ICU following breach of local escalation criteria

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Reinvigorated the Resuscitation Committee

Improved the structure of the committee

Doubled down on training and recognition

ALERT classes for nursing

Friday school for residents

Sim training for response teams

Added an Early Warning Score (EWS) alert system

EPIC iO Artificial Intelligence Alerts – predicting deterioration

We added a Proactive Rounding Early Intervention Nurse

We added a second one when the data proved our need

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What did We Change? / What were our PDSA cycles?

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Statistically Significant Outcomes

Staff Perception of Rapid Response Team Survey

Preventable Mortalities Core TeamBi-Weekly Meetings(Executive Sponsors)

Resuscitation Committee Chairperson(Physician Leader)

Nursing Services Leaders(Operations & Quality)

Program Coordinator

- Acts as subject matter expert in mortality and morbidity outcomes.

- Collaborates with leaders and frontline staff

- Rapidly assesses for improvement opportunities

- Promptly executes quality initiatives to optimize outcomes

- Designs an education, training and research program

Defibrillators

Code Cart &

Regulatory

Process of Care/Equipment &

Response TeamAI Alerts Education & Training Data & Outcomes

Build the Structure

Resuscitation and Early Intervention · • Resuscitation can be the low hanging fruit of reducing hospital mortality. • Done right, you can effectively reduce the raw mortality

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