1. eICU Organ Donation Referral Process
In collaboration with Northwell Health

2. Background

3. 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

5. Organ Donation Performance (pre-project)

6. Tele-ICU

7. “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

8. 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
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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. Goals

15. 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!

16. 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

17. 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

18. 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

19. 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

20. Go-live

21. 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

22. 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

23. Process Map

24. Findings

25. †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.

26. Next Steps

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