2. Leapfrog Who, What, Why, Where,When Gary L. Weinstein M.D. Director of Pulmonary and Critical Care Presbyterian Hospital of Dallas

3. The Leapfrog Group: Who Founded by The Business Roundtable in 2000 Founded by The Business Roundtable in 2000 Consortium of over 120 Fortune 500 companies and other large public and private health care purchasers Consortium of over 120 Fortune 500 companies and other large public and private health care purchasers Provide health benefits to over 34 million Americans in all 50 states Provide health benefits to over 34 million Americans in all 50 states Members and and their employees spend billions on health care each year Members and and their employees spend billions on health care each year

4. The Leapfrog Group: Who Their mission is to trigger a giant “LEAP” forward in quality, customer service and affordability of health care by Their mission is to trigger a giant “LEAP” forward in quality, customer service and affordability of health care by “Making the American public aware of a small number of highly compelling and easily understood advances in patient safety and” “Making the American public aware of a small number of highly compelling and easily understood advances in patient safety and” “Specifying a simple set of purchasing principles designed to promote these safety advances, as well as overall customer value” “Specifying a simple set of purchasing principles designed to promote these safety advances, as well as overall customer value”

5. The Leapfrog Group: Who Their effort is rooted in four ideas: Their effort is rooted in four ideas: American health care remains “far below” obtainable levels of basic safety and overall customer value American health care remains “far below” obtainable levels of basic safety and overall customer value The health care industry would improve more rapidly if purchasers better recognized and rewarded superior safety and value The health care industry would improve more rapidly if purchasers better recognized and rewarded superior safety and value

6. The Leapfrog Group: Who Voluntary adherence to purchasing principles by a critical mass of America’s largest employers would provide a large jump-start and encourage other purchasers to join Voluntary adherence to purchasing principles by a critical mass of America’s largest employers would provide a large jump-start and encourage other purchasers to join These principles should not only champion superior overall value but also focus on a handful of specific innovations offering “great leaps” in basic patient safety to maximize media and consumer support and adoption by other purchasers. These principles should not only champion superior overall value but also focus on a handful of specific innovations offering “great leaps” in basic patient safety to maximize media and consumer support and adoption by other purchasers.

7. The Leapfrog Group: What Initial Leaps in Patient Safety Initial Leaps in Patient Safety Computer Physician Order Entry (CPOE) Computer Physician Order Entry (CPOE) Shown to reduce errors in hospitals by more than 50% Shown to reduce errors in hospitals by more than 50% Evidence-Based Hospital Referral (EHR) Evidence-Based Hospital Referral (EHR) Patients risk of dying could be reduced by more than 30% Patients risk of dying could be reduced by more than 30% ICU Physician Staffing (IPS) ICU Physician Staffing (IPS) Shown to reduce the risk of patients dying in the ICU by more than 10% Shown to reduce the risk of patients dying in the ICU by more than 10%

8. The Leapfrog Group: What Recommendations regarding Critical Care Recommendations regarding Critical Care ICUs should be staffed by Board-certified intensivists, to coordinate and manage care of patients ICUs should be staffed by Board-certified intensivists, to coordinate and manage care of patients Intensivists should staff ICUs during daytime hours, a minimun of 8 hours, 7 days a week Intensivists should staff ICUs during daytime hours, a minimun of 8 hours, 7 days a week Intensivists should respond to more than 95% of calls for assistance within 5 minutes Intensivists should respond to more than 95% of calls for assistance within 5 minutes The intensivist, a FCCS certified physician or “physician extender” should arrive at the bedside within 5 minutes in 95% of cases The intensivist, a FCCS certified physician or “physician extender” should arrive at the bedside within 5 minutes in 95% of cases

9. The Leapfrog Group: Why ICU Physician Staffing (IPS) ICU Physician Staffing (IPS) More than 4 million patients are admitted to ICUs each year in he US 1 More than 4 million patients are admitted to ICUs each year in he US 1 Mortality rates average 10 - 20 % in most hospitals 2 Mortality rates average 10 - 20 % in most hospitals 2 Approximately 500,000 patients die in US ICUs each year 1 Approximately 500,000 patients die in US ICUs each year 1 Quality varies widely across hospitals 3 Quality varies widely across hospitals 3 1. Birkmeyer VD et al. Leapfrog safety standards: potential benefits of universal adoption. The Leapfrog Group. Washington, DC: 2000 2. Zimmerman JE et al. Evaluation of APACHE III predictions of hospital mortality in an independent database. Crit Care Med. 1998;26:1317-26. 3. Knaus WA et al. Variations in mortality and length of stay in intensive care units. Ann Int Med. 1993;118:753-61

10. The Leapfrog Group: Why Evidence Based Medicine in the ICU: Evidence Based Medicine in the ICU: Drakulovic, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 1999;354: 1851. Drakulovic, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 1999;354: 1851. Cook, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med 1998; 338: 791 Cook, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med 1998; 338: 791 Attia, et al. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 2001; 161:1268 Attia, et al. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 2001; 161:1268 Pronovost et al. Improving Communication in the ICU using Daily Goals. J Crit Care 2003;18 vol 2: 71-75 Pronovost et al. Improving Communication in the ICU using Daily Goals. J Crit Care 2003;18 vol 2: 71-75

11. The Leapfrog Group: Why Evidence Based Medicine in the ICU:(cont’d) Evidence Based Medicine in the ICU:(cont’d) Kress, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471. Kress, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471. E. Wesley Ely. Effects on the duration of mechanical ventilation of identifying patients capable of breathing spontaneouly. N Engl J Med 1996; 335: 1864. E. Wesley Ely. Effects on the duration of mechanical ventilation of identifying patients capable of breathing spontaneouly. N Engl J Med 1996; 335: 1864. Herbert, et al. A multicenter, randomized, controlled trial of transfusion requirements in critical care. N Engl J Med 1999; 340: 409. Herbert, et al. A multicenter, randomized, controlled trial of transfusion requirements in critical care. N Engl J Med 1999; 340: 409. Wu, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345:1230. Wu, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345:1230. Van den Berghe, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359 Van den Berghe, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359

12. The Leapfrog Group: Why Evidence Based Medicine in the ICU:(cont’d) Evidence Based Medicine in the ICU:(cont’d) Brown, et al. Effect of ICU mortality of a full-time critical care specialist. Chest. 1989;96:127-129 (ICU mort from 27.8% to 13.4%, hospital mortality from 35.5% to 24.5%) Brown, et al. Effect of ICU mortality of a full-time critical care specialist. Chest. 1989;96:127-129 (ICU mort from 27.8% to 13.4%, hospital mortality from 35.5% to 24.5%) Manthous, et al. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proc. 1997;72:391-399 (Hospital mortality from 34% to 25 %, hospital stay reduced by 5 days, improved housestaff knowledge) Manthous, et al. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proc. 1997;72:391-399 (Hospital mortality from 34% to 25 %, hospital stay reduced by 5 days, improved housestaff knowledge) Hanson, et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274 (No effect on mortality; fewer complication (0.5 vs 1.7 per patient); shorter ICU ( 2 vs 2.8 days) and hospital ( 20.3 vs 23.6 days) stay; lower cost ($34,500 vs $47,500) Hanson, et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274 (No effect on mortality; fewer complication (0.5 vs 1.7 per patient); shorter ICU ( 2 vs 2.8 days) and hospital ( 20.3 vs 23.6 days) stay; lower cost ($34,500 vs $47,500)

13. The Leapfrog Group: Why Review of published data regarding IPS in the Feb 2004, Am J Med: Review of published data regarding IPS in the Feb 2004, Am J Med: Many of the Leapfrog group’s standards for critical care are not grounded sufficiently in evidence to mandate their implementation Many of the Leapfrog group’s standards for critical care are not grounded sufficiently in evidence to mandate their implementation Outcomes of critically ill patients are better when their care is managed directly or with the help of intensivists 1 Outcomes of critically ill patients are better when their care is managed directly or with the help of intensivists 1 Pronovost et al. Physician staffing patterns and clinical outcomes in critically ill patients. A systematic review. JAMA. 2002;6:2151-2162.

14. The Leapfrog Group: Where Wave 1 - 2001 Wave 1 - 2001 Atlanta, GA Atlanta, GA California California Knoxville TN Knoxville TN Minneapolis, MN Minneapolis, MN St. Louis, MO St. Louis, MO Seattle, WA Seattle, WA Michigan Michigan

15. The Leapfrog Group: Where Wave 2 - 2002 Wave 2 - 2002 Central Florida Central Florida Colorado Colorado Dallas-Fort Worth, TX Dallas-Fort Worth, TX Kansas City, MO Kansas City, MO Wisconsin Wisconsin Massachusetts Massachusetts Memphis, TN Memphis, TN New Jersey New Jersey New York Metro New York Metro Rochester, NY Rochester, NY Savannah, GA Savannah, GA Wichita, KS Wichita, KS

16. The Leapfrog Group: Where Wave 3 - 2003 Wave 3 - 2003 Hampton Roads, VA Hampton Roads, VA Illinois Illinois Maine Maine

17. The Leapfrog Group As of October 2003: As of October 2003: Over 1000 hospitals voluntarily participated in the online survey to report their progress towards implementing the recommended practices Over 1000 hospitals voluntarily participated in the online survey to report their progress towards implementing the recommended practices 5% of hospitals in the regional roll-outs report they have implemented CPOE, and an additional 17% committed to implement CPOE by 2005 5% of hospitals in the regional roll-outs report they have implemented CPOE, and an additional 17% committed to implement CPOE by 2005 21% have implemented ICU Physician Staffing and an additional 5.4% have committed to by 2004 21% have implemented ICU Physician Staffing and an additional 5.4% have committed to by 2004 80% of health care consumers in the US now have access to patient safety data for one or more hospitals in their area 80% of health care consumers in the US now have access to patient safety data for one or more hospitals in their area

18. The Leapfrog Group: DFW DFWBGH is the local representative DFWBGH is the local representative 3 workgroups made up of system administrators, system administrators and DFWBGH members 3 workgroups made up of system administrators, system administrators and DFWBGH members ICU outcomes ICU outcomes CPOE CPOE Evidence based referral Evidence based referral Meeting for about 1 year and have accomplished ???????? Meeting for about 1 year and have accomplished ????????

19. The Leapfrog Group QUESTIONS?