“Risky States” Optimizing ICU Safety Through Patient Engagement, System Science and Information Technology Beth Israel Deaconess Medical Center; MIT; Aptima Abstract Objective Methods Results Conclusions Collaborators Funded by the generosity of the Gordon and Betty Moore Foundation • We used existing data and expert analysis to identify fundamental risky states (risk events/event drivers) in the ICU environment, system and people in the system that impact the likelihood of risky events or actual harm to occur. • We identified corresponding harm outcomes during and following these “risky states” and will use them to inform the development of new holistic mitigation strategies • Acquired and reviewed 2 years of retrospective data • Analyzed retrospective data and develop model • Designed application to display real time information to ICU staff about risky level • It was impossible to create a working list of MD’s and RN’s assigned to care for each ICU patient at any point in time from existing electronic data sources •It will be important to capture “drivers” that we have not considered in the first analysis of retrospective data 1. Identified drivers through retrospective review of root cause analyses 2. Identified harms (voluntary reports, billing data, IHI ICU global triggers tool 3. Analyzed 2 years of retrospective data for all ICU patients 2012 – 2014 “ICU Intensity Index” Dashboard Team Environm entPredictors -D rivers Acuity SOFA Score TISS-28 Unplanned Procedures Length ofUnitStay Length ofHospital Stay Ptsin first24 hrs Experience FloatNurse New Nurse <1 year Traveling Nurse Rare UnitProcedure Inexperience w ith Procedure Care Team Boarding Patient OtherEvents Readmission "ED Critical" Adm ission w ith no PastHistory Adm ission from outside Hospital NightvsDay W eekend vsW eekday Special Event National Conference Utilization HoursofCare Bed Utilization Resource Nurse Assignm ents Adm issions Discharges “Total Burden ofH arm ” Preventable Harm s CLABSI VAC/IVAC/PossVAP/ProbVAP High Tidal Volum e VTE-PE ICU-Acquired Delirium Decrease in Function M obility * Falls M edication Events CAUTI Potentially Preventable Harm s ICU-Acquired Pressure Ulcer PTT > 100 w hile on Heparin INR > 6 w hile on W arfarin Hypoglycem ina w hile on Heparin Infusion Oversedation Oversedation requiring Naloxone IatrogenicPneum othorax Reintubation./Unplanned extubation Readm ission to ICU Positive C. Diffand Blood Culture … Potential Harm s Bleeding Lab Specim en Errors Identification Errors Reintubation and Unplanned Extubation Adm inistering Naloxone Adm inistering Vitam in K BUN orCreatinine Doubled Baseline • Dustin Boone • Tricia Bourie • Christina Cain • M ichael Cocchi • Jane Foley • AgnesHu (M IT) • RetsefLevi (M IT) • Lisa Lucia (Aptim a, Inc.) • Yiyin M a (M IT) • Ariel M ueller • Sharon O’Donoghue • Kristin O’Reilly • Jerem y Richards • Adam Traina (M IT) • Donna W illiam s • Kathryn Zieja • Nurse Consultants – Juliann Corey – Lynn M ackinson – Veronica Kelly PI’s • Danny Talm or • Ken Sands