A Transport Pack for OR to ICU Transfers May 1, 2018 Josh Douin, CA-3    Brian Duggar, CA-3     Vladimir Krepostin, CA-2     Stephen Antonovich, CA-2 Thomas Gulvezan, CA-1     Michael Canepa, CA-1

Outline Identify the Problem Propose a Solution Assess Impact OR Efficiency Patient Safety Equipment Costs

Background Transfers from OR to ICU can be dangerous Current method is ad-hoc i.e. Whatever equipment the individual provider remembers to grab

Adverse Events During Transport More common than we think... Any Adverse Event 22-68% Serious Adverse Event 4.2-31% Minor adverse event "physiological decline of more than 20% compared to clinical status before transport, or problem due to equipment" Serious adverse events "put the patient's life at risk and require intervention" Fanara et al, 2010

Serious Adverse Events Cardiac Arrest Severe Hyper- or Hypotension  Arrhythmia Hypoxia, Bronchospasm, PTX Extubation Death Minor adverse event "physiological decline of more than 20% compared to clinical status before transport, or problem due to equipment" Serious adverse events "put the patient's life at risk and require intervention" Fanara et al, 2010

Click to add text Fanara et al, 2010

Current Solution Gather equipment Individually At the discretion of the provider Important Items Frequently Forgotten 

Project Goals Standardize Equipment Improve Patient safety Decrease Costs and Conserve Resources Improve OR Efficiency Standardize Emergency Equipment via pre-made “transport pack” Decrease costs by using already existing equipment and minimizing equipment lost or unrecovered

Project Design Create standardized “Transport Packs” patients requiring direct transfer from OR to ICU start with Whipple and Hepatectomy procedures Measure utilization rates, Satisfaction & transport times Feb-Apr 2018 vs. Jan-Dec 2017 Several authors1,2,3,4,5 offer suggestions to improve the safety of transporting critically ill patients. Standardize procedures and personnel 2) Organization and Equipment 3) Checklists

Uses existing ambu bag, existing ETT and disposable handle/blade

Emergency medications (requested by 96% of respondents)are net yet included due to:  1) Sterility and expiration concerns – per Dr. Seres 2)Cost Note Disposable blades/handles --> approximately 1/10 cost of traditional LED handles and blades ($120 vs. $14) Remainder of equipment is already purchased by the university 

Unfortunately due to pharmacy restrictions we are unable to provide even pre-mixed medications in the transport pack

Results Up to $8,000 of yearly cost savings Unable to demonstrate improved OR Efficiency at this early stage High Provider Satisfaction & Safety Improvement Larger “n” needed to show improved efficiency

Surgery End to Anes Stop 29.8 29.3 -0.5 (-6.3, 7.2) 0.883 Outcome 2017 Mean (N=84) Feb-Apr 2018 Mean (N=9) Mean Difference (95% CI) p-value Surgery End to Out Room 13.8 10.4 -3.3 (-2.5, 9.2) 0.238 Out Room to Anes Stop 16 18.9 2.9 (-8.5, 2.8) 0.286 Surgery End to Anes Stop 29.8 29.3 -0.5 (-6.3, 7.2) 0.883 Larger “n” from 2018 likely needed

Figure 1: Mean transport times for 2017 (control) and Feb-April 2018

Patient Safety 76% of Providers satisfied with emergency supplies in pack Feel more comfortable and safe in event of airway compromise Standardized process decreases error No local outcomes data to date 

Equipment Savings the following are misplaced or lost weekly: 2-3 LED Laryngoscope Handles ($90 each)  2-3 Laryngoscope Blades ($30 each)  ~50% eventually return Total Department Losses:  $60-$180 per week  $3,120-$9,360 per year

Disposable Laryngoscope Handle Item Total Disposable Laryngoscope Handle $4.46 Disp. Mac 4 Blade $3.62 Disp. Miller 2 Blade 7.0mm ETT $1.42 ETT Stylet $1.62 90mm OPA $0.43 10mL Saline Flush $0.22 10mL Syringe $0.06 Ambu Bag $8.06 TOTAL $23.51 Also include costs of lost equipment

Equipment Savings Department Losses: $3,120-$9,360 per year Cost per Trasport pack: $23.51  To date, zero transport packs have been misplaced  Extrapolating from ~5 packs used per month, total yearly cost for transport packs: $1411 Minimum Total Equipment Savings: $1,709-7,949 Minimum Savings assumes that when a transport pack is used, EVERY item in the pack is used.  In practice, this very unlikely to be the case but we do not yet have enough data to support this claim

Lessons Learned Changing practice is challenging Attempting to avoid a rare event is not sexy

CEPs-RF Fund Use Derek Hawes; Epic Data Gathering Alex Kaizer, PhD; Bio-Statistician Colleen Dingmann, RN, PhD; IRB Is this a necessary slide for the anesthesia department presentation?

Thank You Mentors: Erik Nelson, MD; Sukhbir Walha, MD Melanie Donnelly, MD; Alison Brainard, MD CEPS-RF Team: Darlene Tad-Y, MD Anunta Virapongse, MD Heather Hallman

References 1) Link J, et al. Intra hospital transport of critically ill patients. Crit Care Med 1990;18:1427-9 2) Beckmann U, et al. Incidents relating to the intra hospital transfer of critically ill patients: An analysis of the reports submitted to the Australian incident monitoring study in intensive care. Intensive Care Med 2004;30:1579-85. 3) Venkategowda PM et al. Unexpected events occuring during the transport of critically ill ICU patients. Indian J Crit Care Med 2014;18(6):354-7 4)Warren J, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32:256-62 5) Liu J, et al. High incidence of adverse events during intra-hospital transport of critically ill patients and new related risk factors: a prospective multicenter study in China. Critical Care 2016;20(12) 6) Jiang X, et al. Safe transport combined with prospective nursing intervention in intra-hospital transport of emergency critically ill patients. Int J Clin Exp Med 2016;9(7):13166-13171 7) Fanara B, et al. Recommendations for the intra-hospital transport of critically ill patients. Critical Care 2010;14(R87) 8) Brunsweld-Reinders A, et al. A comprehensive method to develop a checlist to increase safety of intra-hospital transport of critically ill patients Critical Care 2015;19(214)

Results Describe data analysis methods Highlight significant outcomes Show a run chart of control chart of your data over the life of the project Charts should be annotated with interventions (see examples on next slide)