2Loma Linda University Medical Center, Loma Linda, CA Avoiding pain, unnecessary interventions and reducing costs in the PICU – a structured approach Jesse Wyatt MD1, Yana Vaks MD1, Anthony Moretti MD, MBA1 , James Pappas MD, MBA2, Michele Wilson MS, RN, NP, CCNS, CCRN1, Carlos Samaoya MPH2 James McGlothlin PhD2, Merrick Lopez MD1 1Loma Linda University Children’s Hospital, Department of Pediatric Critical Care, Loma Linda CA 2Loma Linda University Medical Center, Loma Linda, CA

U.S. Healthcare Spending is Not Sustainable ICU's generate 20-30% of medical costs, plagued by overutilization of high-frequency, low-cost lab and imaging tests, which do not result in higher quality of care. We hypothesize that a rounding tool designed to reduce variability and promote best practices for lab and imaging utilization will cut costs and painful procedures, all while improving patient safety and comfort.

POKE-R= Prevent Pain and Organisms from SKin and Catheter Entry and Radiology NICU Group at Dixie Regional Medical Center Intermountain Healthcare St. George, UT Started by the NICU group at Dixie Regional Medical Center Intermountain Healthcare in St. George, Utah. Demonstrated a substantial reduction in patient harm and a savings of 3.5 million dollars over 5 years. Mention our changes/additions.

A Cohort Study with Historic Controls Intervention: Implement a daily rounding checklist to reduce “POKE-Rs”: Labs IV/IM/SQ medications Imaging studies Stage 1= Historic controls, 546 encounters 10/1/13 to 9/30/14 Stage 2= Cohort, 3,273 encounters 10/1/14 to 12/1/16

Excluded Included All patients followed by the PICU team at a 25-bed tertiary care university PICU. Stage 1- 546 encounters 10/1/13 to 9/30/14 Stage 2- 3,273 encounters 10/1/14 to 12/1/16 Patients required to follow existing lab protocols: ECMO CRRT DKA Stem Cell Transplants

Outcome Measures: Primary outcome: Total number of ”POKE-Rs" per patient per week. Secondary outcomes: Utilization of individual lab and imaging tests and associated costs.

Educational campaign for resident physicians: Lectures Lab order “menu” Chemistry Blood gas $18.00 BMP $14.48 CMP $21.48 LFTs $14.48 CRP $7.91 ESR $8.62 Sodium $7.41 Potassium $7.41 BMP $14.48 Serum Sodium $7.41

Sample POKE-R Data In 2014 our PICU adopted a structured interdisciplinary bedside rounding model, (SIBR). SIBR provided a platform for curbing overutilization. During a set time on rounds, the nurse reports how many "pokes" are anticipated that day and suggests ways to reduce them, followed by a team discussion of the proposed interventions.

Primary Outcome Test Stage 1 Stage 2 POKE-R Count 16 14 MAR 11.8 10.4 “POKE-R”s per patient per week Test Stage 1 Stage 2 POKE-R Count 16 14 MAR 11.8 10.4 POC Labs 1.0 0.7 Non POC Labs 2.5 2.2 Radiology 0.54 0.47 Painful POKE-Rs p<0.0011 p<0.0034 p<0.0641 p<0.0017 p<0.0162

Percent Reduction in POKE-Rs % Reduc T I on 12.5% 12.5% reduction 12% 30% 13% % Reduction Test

Secondary Outcome- Labs per patient per day Diagnosis Labs Stage 1 Stage 2 CSW, DI, SIADH BMP 2.1 1.7 Status Asthmaticus 1.2 Both p<0.0001 BMP- Stage 1= 59 encounters, Stage 2= 279 encounters BMP- Stage 1= 67 encounters, Stage 2= 292 encounters

BMP Percent Reduction Test 29% % BMP BMP Redu c T I on BMP reduction with concomitant increase in individual Serum Na and Serum K. Serum Sodium- Stage 1=0 , Stage 2=256 Serum Potassium- Stage 1=1 , Stage 2= 39 Test BMP BMP

Secondary Outcome- 5 year cost savings Diagnosis Lab Savings CSW, DI, SIADH BMP vs. Serum Na $1,072,518.00 Status Asthmaticus BMP vs. Serum K $1,722,435.00 Based upon 25 bed PICU with CSW, DI, SIADH 30% of patient population and Status Asthmatics 60% of patient populations. Cost Effective Ratio: CER:  $14.48 - $7.41 = $7.07 0.4882  BMP PER PATIENT PER DAY 24.616 – 8.89 5475 7741.65/yr x q6 2.828 12.597   79,410 1527 per week

Conclusion A checklist tool decreased utilization of labs, imaging, and cost when used within structured bedside rounds.

Future Directions Evaluate effects of reducing “POKE-Rs” on: Outcomes (LOS, ventilator days, mortality) Safety Additional Costs

References Algaze, Claudia et al. “Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost.” Pediatrics. Vol 137, number 1, Jan. 2016. Bae, Jong- Myon. “Value-based medicine: concepts and application.” Epidemiology and Health 2015; 37: March 4, 2015. Cooke, Molly. “Cost Consciousness in Patient Care -What Is Medical Education's Responsibility?” New England Journal of Medicine 2010; 362:1253-1255. April 8, 2010. Porter, Michael. “What Is Value in Health Care?” New England Journal of Medicine 2010; 363:2477-2481. December 23, 2010. Weinberger, Steven E. “Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians.” Annals of Internal Medicine. 20 September 2011, Vol 155, No. 6.