1. Hospital and Financial Performance: Improving throughput, flow, and efficiency of care for acutely ill hospitalized patients
J. Christopher Farmer

2. Discussion Points Framing the issues
Where are we now?
What works and what does not?
How do we identify opportunities for gaining efficiency?
Methods to improve flow and throughput
Measuring impact

3. In the hospital: Where are the biggest bottlenecks?
Emergency
Department
ICU
Step
Down
Unit
WARD

4. An average “bottleneck” day?
All ICU beds are “full” with medical patients currently in the CVICU, SICU, and CCU
The intermediate care unit is “full”
Three scheduled CV surgical cases today with one bed opening “later”
Two patients in the ED require MICU admission (beds)
One neuro-ICU patient transfer request pending (acute stroke) from the region
Should we go “on diversion” with EMS?

5. A day in the life of critical care at a busy hospital…
OPERATING
ROOM SERVICES
REGIONAL
REFERRALS
EMERGENCY
DEPARTMENT
“IN-HOUSE”
EMERGENCIES
POST-PROCEDURE
MONITORING
CRITICAL CARE RESOURCE DEMAND
LOCAL
REFERRALS
LIMITED AVAILABILITY RESOURCES
MANY DECISION-MAKERS
VARIABLE DECISION CRITERIA APPLIED
MICU
CV-ICU
INTERMED.
CARE UNIT
CCU
WARDS
SICU
NeuroICU
TELEM.
“chronic crisis mode”…a global affliction

6. Fixing these problems every day? The turning radius of a cruise ship

7. A critical care reality check…
Most hospitals have enough ICU and acute beds to meet current demand almost every day…
EMS diversion is a widespread problem
REMEMBER: diversion is not a demand management tool…it is an excuse!
Diversion = hospital + physician lost revenue (≈ 37,000 USD/pt.)
No data + no physician engagement = CHAOS
So, hospitals build more ICU beds without changing current practices (a culture change)
This results in little to no net improvement in these problems!

8. In today’s world--where should tertiary hospitals be going?
Development of a hospital service (product) line that meets the internal and external demands of critical care and acute medicine
Personnel
Quality
On-site physician coverage 24/7
Data management
Demand management
Education
Fiscal performance
Longitudinal care

9. What does an acute medicine service line look like?
It links the emergency medicine, the critical care, and hospital medicine physicians into a real or virtual group
This also should include nurses and inpatient pharmacists who work in the ICU, step down unit, and involved wards
It defines protocols and procedures for treating common serious illness that are followed by all team members
Examples include management of sepsis, pneumonia prevention, sedation-delirium management, prevention of catheter infections
It should include hospital management support in order to track cost, length of stay, quality and safety, etc.

10. Maximizing hospital throughput

11. Learn about the “A” team: “prevention” is better than “predicaments”
Assessment of initial/ongoing need for ICU care [APPROPRIATENESS]
Accuracy of initial/subsequent patient placement [EFFICIENCY]
Accurate and timely decision-making [EFFICIENCY]
Availability of reliable “downstream” resources (intermediate care, telemetry, SNF, LTAC, etc.) [EFFICIENCY]
Assessment and reassessment of physiological status and care requirements [DEMAND MANAGEMENT]
Aggressive development/implementation of care “protocolization” [QUALITY, OUTLIER MANAGEMENT]
Attending physician patient management is on-site (intensivist and hospitalist) [QUALITY, OUTLIER MANAGEMENT]
APN’s and other ancillary personnel (data management, pharmacy, RT, etc.) [EFFICIENCY, DEMAND MANAGEMENT, QUALITY]
Availability of important clinical and administrative data for “real-time” decision-making (severity of illness, other clinical, UR, cost) [DEMAND MANAGEMENT, QUALITY, OUTLIER MANAGEMENT]

12. Planning patient “flow”... From the front door to the back door
ACUITY OF ILLNESS
ED or
OUTSIDE
REFERRAL
ICU
ADMISSION
PCU
TRANSFER
WARD
TRANSFER
HOSPITAL
DISMISSAL
Multiple calls
Transfer delays
Bed availability
Admitting physician access
Multiple calls
Transfer delays
Bed availability
Transfer physician access
Multiple calls
Transfer delays
Bed availability
Transfer physician access
Multiple calls
Transfer delays
Bed availability
Transfer physician access
Multiple calls
Transfer delays
Bed availability
Transfer physician access

13. Common themes emerge! Dependence on individuals, not processes
Multiple calls
Transfer delays
Bed availability
Admitting physician access
Dependence on individuals, not processes
Communications not protocolized
Hand-offs not “choreographed”
Delayed decision making (dependent on individuals)
Bed management: reacting to requests versus anticipating needs
Not advancing care plans 24/7!

14. Evolving from demand management versus demand forecasting
6 hour delay
1 day delay
1 day delay
3 day delay
PATIENT IN THE ED NEEDS AN ICU BED
MEDICAL ICU
STEP-DOWN
UNIT
WARD
NURSING
HOME
Do you have a bed?
No, call back in
2-4 hours
No, call back in
2-4 hours
No, call back in
2-4 hours
No, call back in
2-4 hours
Net impact:
5.25 days added to hospital LOS
Additional hospital costs
LOS increases X annual patient load = increased personnel requirement
Increased ICU and Step-down bed requirements
Decreased staff satisfaction (increased frustration)
Quality of care?

15. Evolving from demand management versus demand forecasting
Historical number of admissions during each 6 hour time frame for each day of the week
Step-down
Unit ED
MICU
Ward
Wednesday,
3 admissions
Wednesday,
1 admissions

16. Evolving from demand management versus demand forecasting
0600
ICU
PATIENT
1800
READY
TO GO
WHEN...
READY
TO GO
NOT READY
TO GO
MOVE NOW
ADVANCE THE CARE PLAN
RE-EVALUATE TOMORROW

17. Adequate Intermediate Care Unit resources: Not enough = Continuum of care issues…
CRITICAL
CARE
UNITS
FRONT DOOR
BACK
INTERMEDIATE
CARE
UNIT
DOOR
Bandwidth
Care protocols
Triage guidelines
ICU:PCU bed ratios
Provider non-compliance
Patient volume-induced inefficiencies

18. Defining priorities…

19. An acute medicine development project… You need a “team” that will:
Address ICU throughput and resource utilization issues
Address continuum of care issues
Quantify additional critical care physician and non-physician recruitment needs (staffing model including coverage expectations)
Address critical care quality and patient safety program needs
Address the role of residents in the critical care units
Develop and advance ICU team functionality (doctors, nurses, allied health professionals)
think big, start small, go fast…

20. Address ICU throughput and resource utilization issues
In order to improve access to ICU beds
patients must be accurately triaged and acuity matched to the correct unit
decision-making criteria (admission & discharge, etc.) must be consistent and predictable in all units
there must be sufficient numbers of intermediate care beds (also with disciplined criteria for resource utilization)
a designated physician(s) must oversee processes 1-3 in order to ensure consistency and compliance
Care protocols and bundles should be used in order to optimize efficiency

21. Improving throughput: the bottom line…
Our challenge isn’t knowing what to do to avoid “logjams,” most have that reasonably defined…it’s getting it done (change management)
That’s OK…change management is difficult for every organization
We need to our spend time defining priorities along with the specific strategies to get these implemented!
No accountability = no durable change

22. Intermediate Care Unit
Intermediate Care Unit = Progressive Care Unit
Should be multi-disciplinary or have more than one unit
Need more beds relative to total number of ICU beds!
NO POACHING = NO ICU PATIENTS IN THE PCU
On-site supervision: ICU teams versus ward teams
(recommend considering a hospitalist service)
Need better (and sooner) hand-offs from the ICUs
Palliative care services

23. So what do we do?
Review historical data: who are the patients, where are they coming from, what is wrong with them, what do they need from us? (but don’t linger and over-analyze!)
Review the “pipeline” from the front door to the back door…outline bottlenecks, targets, and then define specific implementation measures (we have a lot of what we need already “on paper”)
Create “Top 10” barrier list and define specific “counter measures”
Create a plan of action…2009, 2010, 2012, 2014 (as part of the 1, 3, and 5 year strategic plans)

24. Historical data review
Performance review
Top 5-10 admission diagnoses to the ICU’s (stratified by unit)
Which (insurance) payment codes are linked to these diagnoses?
LOS (hospital + ICU) for each of these payment codes
Financial performance by payment code (which of these offer the largest [positive and negative] margins? What is our market share for these activities?
Are there other (not top 10) payment code categories with small numbers of patients but strongly positive margins?

25. Yes, the details are important...
Protocolized (standardized) management improves clinical outcomes (published data)
Sepsis
Acute myocardial infarction
Central line insertion and catheter site maintenance
Ventilator use strategies in ARDS
Ventilator bundle
Glucose control
Sedation and delirium management
Surgical site wound care
Daily goals sheet (communications tool)
Communications tools for assessment and transfer to lower levels of care
Rapid response teams
Multidisciplinary, team-based rounds
Use of remote ICU virtual presence monitoring by intensivists and critical care nurses
On-site intensivist program
On-site hospitalist program
Adverse drug event prevention program
TEAM = SUCCESS

26. Summary
If you do not know where you are going...any road will get you there
Recipe for success = plan + timeline + milestones + defined deliverables + accountable individuals + a strong commitment from hospital leadership
Think service line for high acuity medicine
Anticipate, do not simply react
Clinical details matter...decreased LOS, complications, mortality