1. 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

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

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

4. Adverse Events During Transport
More common than we think...
Any Adverse Event 22-68%
Serious Adverse Event %
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

5. 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

6. Click to add text
Fanara et al, 2010

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

8. 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

11. 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

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

13. 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 

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

15. 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

16. 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

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

18. 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 

19. 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

20. 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

21. 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

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

23. 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?

24. 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

26. References
1) Link J, et al. Intra hospital transport of critically ill patients. Crit Care Med 1990;18: ) 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: ) Venkategowda PM et al. Unexpected events occuring during the transport of critically ill ICU patients. Indian J Crit Care Med 2014;18(6): )Warren J, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32: ) 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): ) 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)

27. 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)