eICU Organ Donation Referral Process In collaboration with Northwell Health

Background

System Background Northwell Health is the 9th largest non-profit healthcare system in the United States 21 Hospitals 500+ Critical care beds Services Primary care practices Urgent care centers Outpatient procedure offices

Organ Donation Performance (pre-project)

Tele-ICU

“Necessity is the Mother of Invention” Advent of Tele-ICU Use of IT systems to improve operating efficiency for both remote and on site providers Leap frog recommended dedicated intensivists in ICUs-2000. Shortage of critical care fellowship trained Intensivists Bridging gap in critical care manpower

Technology-enabled Care Model Proven, Predictable and Repeatable RESULTS People Technology Process Enabling tools, continuous monitoring, Interoperability Highly leveraged, centralized, intensivist-led care team System wide approach to critical care 0 10 20 30 40 50 60 70 80 90 100 Health System 13 Health System 14 Health System 17 Health System 16 Health System 15 Health System 19 Health System 18 Health System 11 Health System 10 Health System 9 Health System 12 Health System 2 Health System 1 Health System 4 Health System 3 Health System 7 Health System 6 Health System 5 Health System 8 Ranking first in all seven metrics equals 100. CLINICAL TRANSFORMATION

Structure of a Modern Tele-ICU Addressing critical care access, quality, and cost by creating a system- wide safety net Tertiary Care Center MICU SD SICU CVICU Remotely functioning command center Staffed by a critical care physicians and critical care nurses Connected to bedside ICU by two way audio visual system Set of monitors receiving real time data input of the patient Vendor specific software that analyzes data and generates different outputs ED ICU Community Hospital Critical Access Hospital ICU PACU Tele-ICU Center

Standard Tele-ICU Program Patient Room Remotely functioning command center Staffed by a critical care physicians and critical care nurses Connected to bedside ICU by two way audio visual system Set of monitors receiving real time data input of the patient Vendor specific software that analyzes data and generates different outputs

eCM Multi-tasking Workstation Remotely functioning command center Staffed by a critical care physicians and critical care nurses Connected to bedside ICU by two way audio visual system Set of monitors receiving real time data input of the patient Vendor specific software that analyzes data and generates different outputs

Tele-ICU provider roles Support system for bedside clinicians Continuously advances the on-site treatment plan for the day Identifies trends and prevents problems Responds to emergencies Promotes the practice of Evidence Based medicine and best practices

Northwell Health System Tele-ICU Program Started in Dec 2014 Staffed 24/7 with a critical care physician, two critical care nurses. Advanced care practitioner : 5days/8hours Started with 40 beds now expanded to 125 critical care beds in the health system APACHE IV data collection for ~350 critical care beds.

Goals

Objectives Improve the rate and timeliness at which consultations are made to the OPO Eliminate missed consultations Relieve bedside caregiver burden Improve donation rate Save more lives!

Pre-Implementation Survey Evaluated knowledge, preference and consistency Making the consultation 50.9% Prefer to call 49.1% Prefer not to call Time on the phone 28.1% Appropriate amount of time 35.1% Call takes too long 36.8% No opinion Documenation/charting 38.6% Consistently in the same place 36.8% Could be in one of several locations 25% Not always documented at all

Opportunity Unique workflow of the Tele-ICU RN’s includes assessment of each patient’s neurological status and Glasgow Coma Scale (GCS) for Acute Physiology and Chronic Health Evaluation (APACHE) scores Required rounding makes it a perfect way to identify clinical triggers at regular intervals. All patients evaluated on admission to ICU GCS checks twice daily APACHE is the gold standard of measurement of pt. outcomes based on retrospective data

Blind Study From Feb 12 through April 15th 2016, the Tele-ICU staff kept logs of those patients they identified as meeting the clinical triggers. A post-test was administered after the blind study to tease out any residual knowledge deficits of the Tele-ICU nurses. Process review conducted. Date Time Hospital MRN Last Name First Name Age Trigger Met   Loss of ≥ 2 brainstem reflexes GCS ≤ 5 Family discussion of vent withdrawal

Assessment During the blind study the Tele-ICU staff successfully identified all patients for whom actual referrals were made by the bedside. A majority of the cases were identified by the Tele-ICU nurses earlier than the bedside. Unexpected finding – eICU found cases the bedside didn’t refer. MRR by LiveOnNY showed they met triggers though in all but one case were not medically suitable

Go-live

Documentation Need to standardize documention, created fax sheet and SOP for recording in EMR Tele-ICU fills this out and faxes to bedside for placement in chart then documents in EMR Tele-ICU calls bedside to check on appropriateness of referral

Referral Worked with LiveOnNY call center to develop this eICU fills this out prior to calling LiveOnNY LiveOnNY coordinators reported this is very helpful to speed the process

Process Map

Findings

†Referral Rate refers to the number of patients for whom the hospital called LiveOnNY to evaluate divided by the total number of patients meeting official criteria for referral (determined by medical record review) ††Timely Rate refers to the number of calls made by the hospitals to LiveOnNY for patients meeting agreed-upon criteria within the agreed-upon time-frame (one hour) of the patient meeting those criteria *eICU cohort is comprised of four community hospitals and one tertiary care hospital. **Non-eICU cohort is comprised all other critical care hospitals (15 community/tertiary care hospitals) in the Northwell Health System.

Next Steps

Moving Forward Expand program as Tele-ICU coverage expands Physician engagement APACHE Program utilization