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Are We Making a Difference in Hospital Mortality? The LPCH Experience

Paul Sharek, MD, MPH Medical Director of Quality Management Chief Clinical Patient Safety Officer Lucile Packard Children's Hospital Assistant Professor of Pediatrics Stanford University School of Medicine

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Agenda

Background (risk factors, IHI efforts, etc) Data: Annotated time series Statistics Risk adjustment Discussion: what is causing the improvements? Summary/Conclusions

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Background

"...The alarming truth for patients in US hospitals is that the likelihood of dying is directly correlated with their choice of hospital..." "...Analysis by the IHI using HSMRs has shown that a substantial variation in care /quality of care exists among US hospitals..."

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Background

"...IHI believes that mortality can be consistently reduced through the use of a combination of evidence-based interventions..." "...These early results, coupled with work by other IHI QI Collaboratives, literature, and a growing sense of urgency... led IHI to launch the 100,000 lives campaign in 12.2004..."

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Background: IHI Focus on Mortality

Themes for Deaths in box 4 · Planning Failures ·Poor Handoffs ·Lack of Communication and Teamwork ·Suboptimal Risk Assessment/Delayed Dx · Adverse Events

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Background: Recommendations from IHI

1. Implementation of best practices from the Literature that correlate with decreased mortality 2. Adoption of systems supports (such as reminders and standardization) used in high reliability organizations 3. Identification and differential treatment of High Risk Patients

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Background: Recommendations from IHI Prior to 100,000 Lives Campaign

ICU ·Multidisciplinary Teams ·Shared Daily Goal Sheets ·Optimal Glucose Control ·Vent bundle ·Use Intensivists Non-ICU ·Standardize team communications (SBAR) ·Implement RRTs ·Hospitalist program

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Background: 100,000 Lives Campaign (12.2004)

1. Deploy Rapid Response Teams...at the first sign of patient decline 2. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction...to prevent deaths from heart attack 3. Prevent Adverse Drug Events (ADEs)...by implementing medication reconciliation 4. Prevent Central Line Infections...by implementing a series of interdependent, scientifically grounded steps 5. Prevent Surgical Site Infections...by reliably delivering the correct perioperative antibiotics at the proper time 6. Prevent Ventilator-Associated Pneumonia...by implementing a series of interdependent, scientifically grounded steps

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Results-Annotated Time Series

ADE prevention CABSI ICUs RRT SSI VAP

Multidisciplinary teams Intensivisits

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Goal Sheets Hospitalist SBAR

EMR

Results-Annotated Time Series

ADE prevention CABSI ICUs RRT SSI VAP

Multidisciplinary teams Intensivisits

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Goal Sheets Hospitalist SBAR

EMR

Results: Codes Outside of ICU:

Rate (per 1000 eligible admissions) after RRT implementation

Codes Outside of ICU Rate

Code Rate (per 1000 eligible admissions)

10 9 8 7 6 5 4 3 2 1 0

Mean Code Rate 2.45 Baseline Pre-RRT period

Mean Code Rate 0.69 Post- RRT period

Decrease of 72% p < 0.01

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Ja n0 Ap 1 r- 0 1 Ju l-0 O 1 ct -0 Ja 1 n0 Ap 2 r- 0 2 Ju l-0 O 2 ct -0 Ja 2 n0 Ap 3 r- 0 3 Ju l-0 O 3 ct -0 Ja 3 n0 Ap 4 r- 0 4 Ju l-0 O 4 ct -0 Ja 4 n0 Ap 5 r- 0 Ju 5 l-0 O 5 ct -0 Ja 5 n0 Ap 6 r- 0 Ju 6 l-0 O 6 ct -0 Ja 6 n07

Results: Mortality Rate-Housewide After RRT implementation

Hospital-Wide Mortality Rate

Mortality Rate (per 100 admissions)

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Jul-01

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18% reduction

p < 0.01

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Jul-06

Jul-05

Mar...

Mar...

2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0

Mean Mortality Rate 1.01

Mean Mortality Rate 0.83

1.01

Baseline Pre-RRT period

Post-RRT period

Results: Crude Mortality Rate-Housewide After EMR implementation (18 mos pre and post)

Mean Mortality 0.92

Mean Mortality 0.62

Pre-EMR baseline

Post EMR

32.6% reduction

p < 0.01

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Severity of Illness at LPCH in the rise: CMI (NACHRI "Pediatrics Only")

RRT

EMR

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Mortality Ratios (non-OB)

Baseline Mean 0.79

Post EMR Mean 0.60

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p = 0.01

Effect of Risk Adjustment on Mortality Rates

· Model: ARIMA time series analysis

· adjusts for seasonality · Looks for patterns NOT identified by the model (i.e. confounder impact) · Evaluates for linear trends (pre and post intervention)

· CMI adjusted only

· Decrease in 0.37 deaths per 100 discharges (per month) · P value: < 0.0001 · 65 lives in 18 months

· CMI + RRT adjustment

· Decrease in 0.29 deaths per 100 discharges (per month) · P value 0.0031

· 50 lives saved in 18 months!

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Discussion: Reasons for Continued Mortality Decline

· Rapid Response Team implementation-clear association · Infection rate improvement?

· CABSI reduction slow · NICU successful · PICU/CVICU continue to struggle · SSI reduction successful · VAP work slow traction

· ADE reduction?

· No statistically significant change since EMR implementation · ADE studies in pediatrics suggest rare cause of mortality

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Discussion: Reasons for Continued Mortality Decline · Electronic Medical Record Implementation

· · · · · · Promotes Standardization (order sets, processes) Handoffs improved Communication enhanced (<2% verbal order rate, legibility) Real time decision support Corollary orders Improved Turnaround times for medications/radiology results/labs/etc

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Preview: Next Generation Medication Safety Paul's Practical Solutions to Move Toward High Reliability

Leadership

"Patient first" mantra

Zero defect philosophy

Defects in care not accepted as inevitable

Organizational clarity

Mission statement Goals/incentives aligned

Stop the line

Responsibility to stop dangerous processes and fix

Systems thinking

Human factors integration

Fatigue, staffing ratios, labels

Systems and processes drive outcomes

Standardization Culture

"patients first", collegiality, communication, reporting

Checklists, boarding passes, order sets

Data driven

Data driven and evidenced based decision making

Simulation

Prepare in advance for high risk situations

Technology: Tools for supporting ideal

processes

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Conclusions

· Persistent and statistically significant decrease in Mortality rates (crude AND risk adjusted) at LPCH · Challenging to assign causality

· Most IHI "Big Dot" recommendations in place for many years · 5 of 5 best practices around 100,000 live campaign now in place

· Modeling suggests 2 inflection points critical at LPCH

· RRT implementation · EMR implementation

· EMR associated with significantly decreased mortality rates at LPCH

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