1. 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

2. 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.

3. 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.

4. 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

5. Excluded
Included
All patients followed by the PICU team at a 25-bed tertiary care university PICU.
Stage 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

6. 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.

7. 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

8. 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.

9. 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

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

11. 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

12. 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

13. 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:
 $ $ = $
 BMP PER PATIENT PER DAY
– 8.89
5475
/yr x q6
2.828
12.597
79,410
1527 per week

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

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

16. 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
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: April 8, 2010.
Porter, Michael. “What Is Value in Health Care?” New England Journal of Medicine 2010; 363: 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.