1. Bela Patel MD Associate Professor of Medicine UT Health Science Center Houston Memorial Hermann Hospital – Texas Medical Center

2.  Khalid Almoosa MD  Lillian Kao MD  Pratik Doshi MD  Brandy McKelvy MD  Ruth Siska RN, Tammy Campos RN  Kathy Luther RN, Kathy Masters  Jeffrey Katz MD, Eric Thomas MD  Divisions of Critical Care, Pulmonary and Sleep Medicine  MHH nurses, respiratory therapy, pharmacy

3. 1050 Bed Level 1 Trauma Center 65,000 Emergency Department visits per year ▪ 37% admitted to hospital ▪ 10% ICU Admissions plus Transfers  150 ICU Beds  16 MICU Beds  1200 admissions/year  > 95% capacity

4. MICU

7.  Decrease MICU length of stay by 25% through reduction in complication rates and improvement in compliance with evidenced based practices over 36 months to improve flow and capacity.

18. Delayed ICU transfer (>4 hours from care complete to ICU arrival) ▪ Increased hospital mortality ▪ Increased hospital LOS ▪ Increased ICU LOS Chalfin et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit care med 2007; 35: 1477-83. Admission Delays to the ICU

19. Baseline Data March 08- February 09 Pratik Doshi MD <4 hours>4 hours Patients 345314 % of total patients 52%48% Mortalty Rate 14%17% Hospital LOS 9.1010.30 CMI 2.332.60 Age 5558 % Male52%48% % Female48%52% 30 day readmits 4032 30 day readmits-- Same DRG127 Care Complete to Depart MICU Admits Mortality 18% higher Length of stay 11% higher

20. ICU Transfer EC

25.  RRT protocols and structure have spread to 9 hospitals in the system

27. 1. Serum lactate measured 2. Blood cultures prior to antibiotic administration 3. Broad-spectrum antibiotics administered  Within 3 hours of ED arrival or 1 hour non-ED admission 4. Treat hypotension with fluids +/- vasopressors  Initial minimum of 20 mL/kg of crystalloid  Vasopressors to keep MAP > 65 mm Hg 5. Persistent hypotension  Maintain central venous pressure > 8 mm Hg  Central venous O 2 saturation (Scvo2) > 70%

28. Hyperglycemia protocol

33. MICUICUsEDs 11 Hospital ICUs

38.  Expansion into multiple ICUs next month followed by global implementation for the 11 hospital system MICU TSICU NTICU 11 hospitals

43.  TSICU Zero VAPS for 28 months  CCU Zero VAPS for 18 months  72% Reduction of VAPS across 7 ICUs  Expanded Bundle Elements to 12 hospitals

46.  6 ICUs  7 Hospitals  76% Reduction in Central Line Infections

47. InfectionIncreased LOSAdded cost Pneumonia6$57,000 Bacteremia7$63,000 Wound7$3,100 UTI1$700

49. Patient admitted to the MICU Treatment Family conference High risk of death Palliative care Ethics Delays in family conferences No structure to conferences No process for organizing conferences Inconsistency among MDs No timeline “1 more day” Not multidisciplinary; no attending Delays in palliative care

50. High risk-of- death patients identified Schedule family conference Patient admitted to the MICU Team members notified Family conference Decisions Documentation Future meetings Nurse manager Nurse manager or Social worker

51. Baseline 10.1 days

58.  Through improved quality of care and safe practices, these changes collectively resulted in an overall savings of $5.1 million per year in decreased length of stay  Additional revenue from increased admissions

63.  Thank you