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Outliers and Super Users: Targeting Prolonged Use of MV in the ICU
7 Plays6 years ago
In this episode of Critical Matters, listen to the recording of the Sound Critical Care’s latest webinar, Outliers and Super Users: Targeting Prolonged Use of MV in the ICU. Critically ill patients requiring prolonged mechanical ventilation have poor clinical outcomes and consume a disproportionate amount of resources.
In this webinar, we will discuss outliers and super users in the ICU utilizing prolonged mechanical ventilation as a case study. We will also discuss outcomes for these patients and finally strategies to optimize the care of this difficult patient population.
Watch the video recording: http://bit.ly/2MHL4Ga
Additional Resources:
The Hot Spotters by Atul Gawande: http://bit.ly/36lUdvT
I-TRACH: Validating A Tool for Predicting Prolonged Mechanical Ventilation: http://bit.ly/2SEcOPy
Expectations and outcomes of prolonged mechanical ventilation: http://bit.ly/2QbBDRp
Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis: http://bit.ly/2tjQgJu
Lean Six Sigma to Reduce Intensive Care Unit Length of Stay and Costs in Prolonged Mechanical Ventilation: http://bit.ly/359bYwV
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
Speaker
And now your host, Dr. Sergio Zanotti.
Webinar on ICU Super Users and Outliers
00:00:32
Speaker
So let's get it started with our program.
00:00:35
Speaker
As we mentioned at the beginning, we will do the first part will be an overview of super users, outliers, and prolonged mechanical ventilation, followed by a discussion with Dr. John D'Ambrosio, one of my colleagues, and a Q&A for the audience after that as well.
00:00:53
Speaker
So what we'll do in the first part of this webinar is overall start with an introduction and explore some of the concepts
00:01:02
Speaker
related to outliers, hotspots, and super users, and how that might apply to prolonged mechanical ventilation in the ICU.
Strategies for Prolonged Mechanical Ventilation
00:01:10
Speaker
We will dive a little bit deeper in understanding this particular population that we are addressing today, which is that of prolonged mechanical ventilation, which is a subset of chronically, critically ill patients.
00:01:21
Speaker
And finally, we'll talk about some of the strategies that we can utilize to really create value for this population, both in improving outcomes
00:01:31
Speaker
and decreasing the cost of care for these particular patients.
00:01:37
Speaker
As we all know, the business of healthcare has been changing over the last several decades.
00:01:42
Speaker
What was traditionally a very volume-driven healthcare fee-for-service is moving and evolving into a value-driven healthcare, which is really much more related to the overall value delivery of quality over cost.
From Volume to Value in ICU Care
00:01:59
Speaker
Some aspects of medicine today
00:02:01
Speaker
are still very much in the volume-driven healthcare environment, yet critical care is moving faster probably towards a value-driven healthcare, but really we need to determine what do we do to create value in the ICU.
00:02:16
Speaker
When we think about value or creating value in the ICU, I think it's always a good place to start to review what do we mean by value, and really by value we are talking about improved quality over at a lower cost.
00:02:30
Speaker
So we're trying to drive quality up and drive costs down.
00:02:35
Speaker
And when we think of quality, we're thinking of both patient outcomes and patient experience.
00:02:41
Speaker
Those are both aspects of quality care.
00:02:44
Speaker
And in terms of cost, it both includes direct and indirect costs of caring for patients in the ICU.
00:02:51
Speaker
So a lot of what we'll be talking about today really centers around the creation of value in identifying a special population
00:02:59
Speaker
that we have traditionally ignored that might be very prime for value-based care in the ICU.
00:03:08
Speaker
So what are we talking about?
00:03:09
Speaker
There's three overlapping circles.
00:03:11
Speaker
One of them includes outliers.
00:03:14
Speaker
The other one is super users or hotspots.
00:03:16
Speaker
And then we're trying to apply this to the ICU patient.
00:03:19
Speaker
And what we're really trying to focus or hone on here is where all these diagrams or these circles converge.
00:03:25
Speaker
And that red star really is, as I'll propose to you,
00:03:29
Speaker
One of the groups that falls right in that area is that of prolonged mechanical ventilation and how we can really target these patients in terms of driving value both from a quality outcome perspective, but also being very conscious of how we can manage cost.
00:03:47
Speaker
So let's start by talking about outliers.
00:03:49
Speaker
And the outliers, I mean, from a purely statistical standpoint,
00:03:53
Speaker
are defined are data values or value that lie outside of the overall pattern of a distribution.
00:04:00
Speaker
So usually when something is really one or two standard deviations away from a standard distribution, we talk about an outlier.
00:04:09
Speaker
When we think about what we do in healthcare, especially in the ICU, we measure different processes and outcomes such as hospital length of stay, ICU length of stay,
00:04:20
Speaker
duration of mechanical ventilation, very important for us in the ICU, but also obviously at the heart of what we're talking about today.
00:04:29
Speaker
Certain process metrics such as door to balloon for acute MIs or door to needle for thrombolytics in acute strokes.
00:04:39
Speaker
Also in sepsis might be time to first antibiotic from admission to the ED.
00:04:43
Speaker
All these things are things that we measure over a continuum,
00:04:46
Speaker
And usually what we see is that we talk about means or averages, and that's what we usually talk about in terms of what we're trying to target.
Identifying ICU Care Improvement Signals
00:04:55
Speaker
Some people look at medians, which is really the middle point as opposed to just a mathematical arithmetic average.
00:05:02
Speaker
But we always will find patients who are way out there, usually on the right side of this curve, that we talk about as outliers.
00:05:11
Speaker
And it's not unfrequent when we are talking about any of these
00:05:15
Speaker
particular metrics that we try to discard the outliers and focus on the means and the medians.
00:05:22
Speaker
So really talking about the outliers as something that is noise.
00:05:26
Speaker
And what I'm going to propose today is that perhaps we definitely should focus on those patients in the middle, which is the normal distribution, but there is something in these outliers that requires attention and that can actually constitute a focus of our efforts
00:05:42
Speaker
In other words, the outliers are not the noise, they might be the signal when we're talking about value.
00:05:50
Speaker
So let's talk a little bit now about super users or hotspots and how we came across this concept.
00:05:58
Speaker
So many years ago, in 1896, Pareto was an Italian economist, noted and published an observation that 80% of the land in Italy
00:06:11
Speaker
was owned by 20% of the population.
00:06:14
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And that became very famously after that known as the Pareto Rule or the 80-20 rule.
00:06:21
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And it's an observation that keeps repeating itself in multiple environments, both in business, but also in processes, in healthcare, and in many other areas of life.
Applying the 80-20 Rule in Healthcare
00:06:33
Speaker
And the idea really is, is that a very small number of inputs
00:06:38
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determined the vast majority of the output that you're measuring.
00:06:43
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So 20% of the diagnosis that we see in critical care represent 80% of the patients or the cost of care, et cetera, et cetera.
00:06:53
Speaker
So really trying to focus on what people have come to know as the critical few.
00:06:58
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What are the things that really drive the vast majority of a given output?
00:07:04
Speaker
If you move that forward many, many years, in the recent years,
00:07:08
Speaker
In trying to combat crime in major cities, a lot of police departments have started mapping where crimes occur and creating these crime hotspot maps.
00:07:20
Speaker
And what they've been able to identify is areas where there's a concentration of crime.
00:07:26
Speaker
And what they found in many large cities is that by focusing on these areas and increasing police surveillance in these hotspots,
00:07:34
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you can actually bend the curve of crime and avoid crime.
00:07:38
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And it's really an interesting concept of really trying to focus where the majority of your problems are, understanding that's going to be a very small number of inputs.
00:07:49
Speaker
So how do this applies to healthcare?
00:07:52
Speaker
Well, I think that in the last years, one of my colleagues who was actually in the hospital that I was working prior in Camden at Cooper Health,
00:08:05
Speaker
was one of the pioneers in really thinking about hotspotters in healthcare.
00:08:10
Speaker
And it's a very interesting story.
00:08:11
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The picture there is Dr. Jeff Brenner, who really, I mean, championed this concept of hotspotting or identifying hotspotters in a community.
00:08:21
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And he really took the idea after getting involved with the Camden Police Force, trying to decrease crime in Camden.
00:08:29
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And he was one of the big proponents of using hotspot maps
00:08:32
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And even though the police did not really think that was a good idea or Shanda's idea at the beginning, he quickly started thinking, what would happen if I start mapping the community of Camden in terms of hotspots for healthcare resource utilization?
00:08:50
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And he started working with different databases in the early 2000s, and what he found was that there were two blocks in Camden
00:08:58
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that accounted for an enormous amount of hospital visits and resources.
00:09:03
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And those two blocks included Abigail House, which was a nursing home, and Northgate 2, which is a low-income housing community.
00:09:13
Speaker
And what he found is that in a period of six years, from 2000 to 2008, 900 people from those two blocks represented 4,000 hospital visits
00:09:27
Speaker
hospitals and EDs in Camden, and that equaled a foot bill or a healthcare bill of over $200 million.
Cost-saving with Healthcare Hotspotters
00:09:37
Speaker
So he identified that a very small number of patients were consuming an enormous amount of resources in a very circumscribed and poor community such as Camden, New Jersey.
00:09:50
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Atul Gawande wrote about Dr. Brenner in 2011.
00:09:52
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Following that, Dr. Brenner
00:09:56
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became a MacArthur Genius Awardee.
00:09:58
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He created something that today is known as the Camden Coalition for Healthcare.
00:10:02
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And really by focusing on these hotspotters was able to produce enormous, enormous savings and costs.
00:10:10
Speaker
But more importantly, he was able to improve the healthcare of these super users or hotspotters.
00:10:16
Speaker
What he identified was that outliers matter and that those 900 patients or 1,000 patients roughly
00:10:24
Speaker
represented only 1% of the whole population of Camden, yet they were consuming 30% of the healthcare cost.
00:10:33
Speaker
So if he could bend the curve on that 1%, he could really create significant amounts of savings in healthcare, but more importantly, he was able to improve the healthcare of that community.
00:10:47
Speaker
So Dr. Brenner, I mean, now is, I think, working elsewhere.
00:10:51
Speaker
but taking this idea of hotspotters to a larger platform with UnitedHealthcare.
00:10:56
Speaker
But clearly a lot of cities and practices have adopted this approach of really focusing on their super users and trying to bend the curve there in terms of improving outcomes in terms of quality, but also controlling cost of healthcare by focusing on small number of patients who consume an enormous amount of resources.
Variability in Mechanical Ventilation Care
00:11:20
Speaker
So I think that the argument that we'll make today is that in the ICU, perhaps the hotspotters or one of the big hotspotter groups is prolonged mechanical ventilation.
00:11:32
Speaker
So why do most critical care or sound critical care programs work on duration of mechanical ventilation?
00:11:38
Speaker
Well, I think that there's a lot of reasons.
00:11:40
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And one reason is that clearly it's something that we commonly do in the ICU.
00:11:45
Speaker
I mean, requiring support
00:11:47
Speaker
with a ventilator or a noninvasive ventilation is a common reason, if not the most common reason for admission to a medical ICU.
00:11:55
Speaker
It's also a common reason for surgical patients to be admitted post-surgery to ICUs.
00:12:02
Speaker
A second very powerful reason is that there's tremendous variability in how teams across the country care for this patient, but also there might be variability in how a particular patient during a particular episode of care
00:12:16
Speaker
is cared by an ICU team.
00:12:19
Speaker
And finally, we know that duration of mechanical ventilation or being on a ventilator is associated with significant amounts of increased morbidity and mortality.
00:12:32
Speaker
So clearly being able to liberate patients from mechanical ventilation is an important quality aspect that can improve the outcome of our patients.
00:12:42
Speaker
This is data taken from one of our ICUs.
00:12:44
Speaker
I mean, it's a standard medical ICU, 18-bed ICU.
00:12:49
Speaker
This is one month in January.
00:12:51
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And what you can see here is plotted are all the patients that were on a mechanical ventilator during this month.
00:12:58
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And you can see that you have, for each individual case, you have hours of mechanical ventilation.
00:13:05
Speaker
And what you find is that clearly there is a couple of outliers
00:13:10
Speaker
that seem to have consumed significant more hours than the average or the medium.
00:13:16
Speaker
Traditionally, when ICUs are looking at this, what they'll do is they'll try to disregard the outliers, and especially those on the right, and say, well, these patients are outliers.
00:13:26
Speaker
They don't really represent the quality of what I'm doing in my ICU because my protocols are really geared at the patients in the middle.
00:13:36
Speaker
I would say two things.
00:13:37
Speaker
One is that those patients
00:13:39
Speaker
Those first three patients that are on the left side that had a very short duration of mechanical ventilation are also outliers, yet nobody seems to worry about those because they usually make the number which we try to target for, which is a lower number, look better.
00:13:55
Speaker
But the number two is that I wouldn't ignore the outliers.
00:13:58
Speaker
I would just maybe think that are there different things that we could do to understand and to target these particular patients that might be
00:14:07
Speaker
a prime example of hotspotters in the ICU.
00:14:10
Speaker
So here you have the same data expressed in a table.
00:14:15
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So we had 56 total occurrences of mechanical ventilation.
00:14:19
Speaker
For a total mechanical ventilation hours for the month of January of 4,766 hours, the average duration of mechanical ventilation was 86 hours.
00:14:29
Speaker
And when you look at the average duration of mechanical ventilation days,
00:14:33
Speaker
it was around 3.6.
00:14:33
Speaker
So that's kind of what most people talk about when they say, oh, my average duration of counterventilation is 3.5, 3, 2.8 days.
00:14:41
Speaker
We're talking about an average over a given time period.
00:14:45
Speaker
If you now break up or add more data, you can look at the geometric mean, you can look at the median, which we said is not the mathematical average, but the middle point, you can maybe exclude outliers on both sides, and you see that the medium in terms of days
00:15:01
Speaker
and in terms of hours is lower than the average.
00:15:04
Speaker
For this particular ICU, they had a target of 60 hours for their median, so they would say that they're in compliance with their targets, which are arbitrary, obviously.
00:15:13
Speaker
But when you dig a little bit deeper and we start looking at what happens to those patients who are on the vent for less or for more than seven days, and what we say, okay, if the average is 3.6 or 2.3, the median, seven days or more would be
00:15:30
Speaker
beyond what we consider to be average or that normal range.
00:15:33
Speaker
So they might be falling into a more prolonged course or maybe at a higher risk of being true outliers.
00:15:41
Speaker
Now, what we see is that of all the patients that were on the ventilator, those who were on the ventilator for less than seven days, on average, were on the ventilator for 2.5 days.
00:15:53
Speaker
And these are the patients that usually have an acute illness, are weaned successfully,
00:15:59
Speaker
by following our protocols, and that represented the majority of the patients, 47, yet in terms of the total percent of days consumed or the total days of mechanical ventilation, it's only 58%.
00:16:14
Speaker
So there's still a big chunk of mechanical ventilation hours to be accounted for.
00:16:19
Speaker
When we look at those patients who were on the mechanical ventilator for more than seven days, their average now is 10.3.
00:16:27
Speaker
So clearly these groups are significantly
00:16:30
Speaker
different.
00:16:30
Speaker
And these would be considered outliers.
00:16:33
Speaker
There are two standard deviations beyond what we see for the average for all patients.
00:16:41
Speaker
These were eight patients, which is a little bit, I mean, more than 10% of the patients, yet they consumed 42% of the total hours of mechanical ventilation.
00:16:55
Speaker
So clearly, this is a hot spot.
00:16:59
Speaker
a small group of patients who consume a disproportionate amount of resources, and we are quantifying resources here as days on mechanical ventilation.
00:17:10
Speaker
So if we were to say that for each hour of mechanical ventilation, we could assign a dollar cost, right, we would say that a very small percent of the patients consumed 42 percent of the total cost of care for these patients.
00:17:28
Speaker
So again, I mean, I think it illustrates how this particular group might be a prime target for a hotspotter or super user approach to drive value.
00:17:40
Speaker
So a hotspot in prolonged mechanical ventilation is a hotspot, is a small group of patients with a large impact on the utilization of resources.
00:17:50
Speaker
So for mechanical ventilation, as we saw, they constitute a very small number of, in terms of number of patients,
00:17:58
Speaker
yet they consume a disproportionately large amount of hours or days of mechanical ventilation.
Literature on Prolonged Mechanical Ventilation
00:18:06
Speaker
So when we think about that Venn diagram I showed with the outliers, the super user hotspots, and the ICU patients, I think that prolonged mechanical ventilation falls into that spot very, very nicely, and that's why we're talking about that today.
00:18:25
Speaker
So let's
00:18:26
Speaker
dive in a little bit more into this world of prolonged mechanical ventilation and just explore what do we know about prolonged mechanical ventilation?
00:18:34
Speaker
What does the literature afford us in terms of understanding this population a little bit better?
00:18:40
Speaker
So when you look at different reviews in the literature, what you'll find is that there are a large number of terms and different definitions that people have utilized to describe the same group of patients.
00:18:54
Speaker
patients who are on the ventilator longer than what you would consider your average of, let's say, 3.5 days.
00:19:02
Speaker
So that includes prolonged mechanical ventilation.
00:19:04
Speaker
Some people have tackled these by admission to a specialized unit that specializes in weaning patients off mechanical ventilation.
00:19:12
Speaker
People have talked about long-term mechanical ventilation.
00:19:15
Speaker
Chronic critical illness is obviously a topic or a subset of patients
00:19:22
Speaker
that has received a lot of attention in the last decade, and it is these patients that don't die but don't fully recover and are chronically critically ill and the one type of patients that go to long-term acute care centers or patients who stay in the ICU for a long time.
00:19:37
Speaker
Some people have looked at tracheostomy as the event that classifies these patients as being prolonged mechanical ventilation.
00:19:46
Speaker
Some people talked about ventilator dependence, but really
00:19:48
Speaker
A large number of definitions and terms are utilized, but when we look at this, what I like to think about is the group that really starts after 96 hours.
00:20:00
Speaker
So this is based on our ICD code 96.72, that is 96 hours or more of mechanical ventilation.
00:20:08
Speaker
Before four days, I think that it's hard to talk up, even start thinking about prolonged mechanical ventilation, but when somebody starts to pass day five and further,
00:20:18
Speaker
you might start looking at somebody who's at high risk of being on prolonged or a more prolonged course on mechanical ventilation.
00:20:27
Speaker
What's the official definition of prolonged mechanical ventilation?
00:20:30
Speaker
According to the Centers for Medicare and Medicaid Services in the United States, and this is a definition that is taken from the National Association for Medical Direction and Respiratory Care, it is 21 consecutive days with six or more hours per day
00:20:46
Speaker
of mechanical ventilation support.
00:20:48
Speaker
That is what defines prolonged mechanical ventilation in Medicare and Medicaid Services' view.
00:20:55
Speaker
And I think it's an operational definition that I think is worthwhile, but the idea really is that we should be doing things and thinking about these patients way before 21 days, and that's why I like to think of kind of four days if somebody's still on the ventilator, these patients might not be
00:21:16
Speaker
or might be at a higher risk of not being extubated immediately, and we should start thinking about what can we do to move this forward.
00:21:24
Speaker
As I mentioned earlier, tracheostomy is obviously a sentinel event in these patients.
00:21:31
Speaker
A lot of these patients will eventually be ventilated through tracheostomy for many, many reasons.
00:21:37
Speaker
There are DRG codes that can be utilized to identify these patients retrospectively.
00:21:43
Speaker
The DRG codes that most people look at are DRG4 and 5.
00:21:47
Speaker
And really, I mean, what you'll find is that these patients on average will have significant length of stays in terms of what is documented based on the APA DRGs nationally.
00:22:01
Speaker
So the tracheostomy might be another way of identifying these patients.
00:22:07
Speaker
Why do these patients stay on the ventilator?
00:22:09
Speaker
So the pathophysiology of phalanomechanical ventilation obviously is a very complex topic, but I think that at its essence, it's a disbalance or an imbalance between an increased respiratory load and a decreased respiratory muscle performance.
00:22:27
Speaker
So when patients have this balance, they are likely to remain on the ventilator.
00:22:34
Speaker
And there are many, many reasons, many reasons in critical illness
00:22:37
Speaker
that can lead to this, but understanding this disbalance, I think at its essence, is a good way to start thinking about the pathophysiology of prolonal mechanical ventilation.
00:22:47
Speaker
What are identifiers or what are some of the factors that we could utilize to predict who will be on prolonal mechanical ventilation?
00:22:58
Speaker
That obviously is something that makes sense if you could know from the get-go this patient is going to require a trach,
00:23:04
Speaker
you could probably intervene with the family a lot earlier.
00:23:08
Speaker
Unfortunately, we don't have a perfect eight ball that can really tell us what the trajectory is, but there's some studies that have looked at this.
00:23:16
Speaker
Back in 1996, Seneff did a very large study where they looked at what are the factors that predict duration of mechanical ventilation, and he really focused on a lot of the patient factors and determined that the greatest determinant is disease.
00:23:31
Speaker
The second greater determinant is the acute physiologic score or the acuity.
00:23:35
Speaker
And then he found some other things that related to these patients in terms of predicting a prolonged mechanical ventilation.
00:23:45
Speaker
I think that all of these are very important, but a lot of these might not be modifiable.
00:23:52
Speaker
They depend on the disease.
00:23:54
Speaker
What we also now believe, and although there's no good studies about this, is that our processes of care
00:24:00
Speaker
also have a tremendous impact on whether somebody will have a prolonged duration of mechanical ventilation.
00:24:06
Speaker
And we'll talk more about that a little bit further on.
00:24:12
Speaker
This is a more recent study that suggests a simple tool that can be utilized to predict prolonged mechanical ventilation.
00:24:20
Speaker
It's called the eye track.
00:24:22
Speaker
And the idea is that for each one of these, you give the patient a point.
00:24:28
Speaker
I actually stands for intubation in the ICU, so that would be a point.
00:24:32
Speaker
And you do this at the time of intubation.
00:24:34
Speaker
If they're tachycardic, they have renal dysfunction as measured by a BUN over 25, they have acidemia with a pH below 725, they have a creatinine of 2.0 or a 50% increase in their creatinine, or they have a bicarb below 20, you can give a point for each one of these.
00:24:52
Speaker
And when patients have four or more, it is more likely that they will
00:24:56
Speaker
require seven days or more of mechanical ventilation and also more likely they require 14 days or more of mechanical ventilation.
00:25:03
Speaker
So the higher the points of the eye trach, the higher the likelihood that they would require prolonged mechanical ventilation.
00:25:12
Speaker
When you look at the receiving operating curve, you can see that even though it's not perfect, it does have a better performance than just utilizing
00:25:21
Speaker
a severity score such as Apache 3, Apache 2, the SOFA score, or just purely the acute physiologic score.
00:25:28
Speaker
So again, I think it helps us think about patients that are higher risk, but I don't think that it's actionable at that time because in theory you wouldn't change the way you treat these patients on day one and you wouldn't decide that they're going to do it, for example, a tracheostomy on day one, but it can be a way of thinking of these patients as being at higher risk.
00:25:52
Speaker
Like I said, on average, most of our patients will be weaned within a certain timeframe.
00:25:59
Speaker
Like the data I showed you was an average of 3.5 days of mechanical ventilation.
00:26:03
Speaker
But I do think that in those patients who don't wean once their acute episode is immediately corrected, the first or second attempt to weaning, we should start thinking about what are some of the things that we need to evaluate to optimize the weaning process in these patients as they start moving
00:26:20
Speaker
into a prolonged mechanical ventilation phase.
00:26:23
Speaker
And there are things like thinking of the cardiovascular state.
00:26:26
Speaker
The most common things that can prevent weaning are heart failure and ischemia.
00:26:31
Speaker
There's ways to figure this out.
00:26:33
Speaker
Looking at metabolic factors such as electrolytes, phosphorus, magnesium, calcium are important ones for weaning.
00:26:40
Speaker
Endoquine is important, although not that frequent, but clearly patients who have untreated hypothyroidism
00:26:46
Speaker
might have difficulty weaning and prolonged mechanical ventilation.
00:26:50
Speaker
So something to think about in the right context.
00:26:53
Speaker
Infection is a very common cause of failure to wean, not only having infection with sepsis, but even patients who have a systemic inflammatory response.
00:27:03
Speaker
Things that we need to evaluate.
00:27:05
Speaker
Are there nosocomial infections that are causing a delay in weaning?
00:27:09
Speaker
Nutrition, both over and under nutrition,
00:27:13
Speaker
can cause problems.
00:27:14
Speaker
Overfeeding and those who have a limited ability to eliminate CO2 can be a problem for weaning.
00:27:20
Speaker
Not common, but in some subsets of patients, something that we need to pay attention to.
00:27:24
Speaker
Obviously drugs, something that I think with now, I mean the much more common occurrence of having pharmacists, clinical pharmacists rounding with us should be less of a problem.
00:27:35
Speaker
But making sure that we're evaluating any drugs that can suppress the respiratory drive or induce respiratory weakness.
00:27:42
Speaker
And finally, there are some patients who do have psychological fears to the weaning process.
00:27:47
Speaker
And in these patients, obviously, the interventions to decrease the presence of delirium and early mobility with biofeedback for their anxiety might be tools that can help them get off the mechanical ventilator sooner.
00:28:02
Speaker
A big question in prolonged mechanical ventilation relates to the timing of tracheostomy.
00:28:08
Speaker
And this is always something that people argue about.
00:28:12
Speaker
The reality is that we don't have any clear-cut data that can, for every patient, tell us this is the perfect time to trach.
Optimal Timing for Tracheostomy: A Debate
00:28:21
Speaker
On one hand, I think that people, both physicians and families, sometimes want to avoid another procedure.
00:28:30
Speaker
On the other hand, anecdotally, patients who have been, who have received tracheostomies and survived will invariably ask, why did you trach me before?
00:28:41
Speaker
because it was much more comfortable having a tracheostomy than an ET tube going down my throat.
00:28:46
Speaker
So when you look at the literature and we look at the current guidelines, I think that most people would agree that tracheing large populations of critically ill patients before day four probably offers no benefit, and that would be very, very early tracheostomy.
00:29:04
Speaker
However, as you move forward,
00:29:06
Speaker
The idea, the traditional idea that at two weeks you start thinking about that, which really can push things forward, is probably too late.
00:29:13
Speaker
Some people have done studies 10 days early, more than 10 days late, and there's been studies that have shown that that early trach might be associated with better outcomes.
00:29:24
Speaker
And many studies have also looked at seven days, and although they've not shown improvements in mortality, they clearly have shown decreases in certain outcomes and morbidity.
00:29:34
Speaker
So, again, I think that the
00:29:36
Speaker
The sweet spot probably is around seven days to start thinking about if a patient needs to be trached or not.
00:29:43
Speaker
Not to necessarily need to trach a patient on day seven, but by that day you should have an idea what the plan is to wean them or if the patient is suitable for a tracheostomy.
00:29:53
Speaker
So again, I mean, these are just some dates that have been thrown around, but I want to emphasize that we really don't have clear directives based on evidence on what's the perfect timing, but most people would agree that earlier
00:30:05
Speaker
is better without being too early where you really, I mean, might do a trick that's unnecessary.
00:30:13
Speaker
What are some of the complications associated with prolonged mechanical ventilation?
00:30:17
Speaker
Some of the complications are very similar to those that we see in patients who are just on mechanical ventilation for a shorter time.
00:30:23
Speaker
Some of them might be more pronounced or more likely the longer you stay on the ventilator.
00:30:28
Speaker
Infection, clearly an important one, and not only ventilator-associated pneumonias, but also
00:30:36
Speaker
other nosocomial infections such as CLABSI, catheter-associated urinary tract infections, and C. diff.
00:30:43
Speaker
Renal failure is often seen in critically ill patients and clearly can be a complicating factor in patients who have a lot of mechanical ventilation.
00:30:50
Speaker
As we'll see further on, it's actually a pretty strong determinant of poor outcome.
00:30:55
Speaker
Ill use is commonly seen in these patients.
00:30:57
Speaker
Those patients who have an ET2 for a long time can have laryngeal edema and trichumelacia and other types of
00:31:05
Speaker
of injuries to the airways.
00:31:07
Speaker
Patients who have a tracheostomy are often at risk for complications associated with a tracheostomy, including infection and bleeding and the more catastrophic but not as frequent complication of a fistula that sometimes can go into an enominate artery.
00:31:26
Speaker
It can cause a hemorrhagic shock and death.
00:31:29
Speaker
And also pneumothorax is something that we see more frequently the longer somebody stays
00:31:34
Speaker
on a mechanical ventilator.
00:31:37
Speaker
As we move to prognosis, one of the studies that I find fascinating was a study done by Cox and collaborators looking at the perception at the time of tracheostomy of what the outcome would be from families, looking at what the physicians would think, and then finally following these patients for a year and looking at what reality really showed.
00:32:02
Speaker
And what they found
00:32:03
Speaker
was that there is significant misaligned expectations between caregivers and decision makers and clinicians caring for the patient.
00:32:14
Speaker
At the time of tracheostomy, when they asked family members what was the likelihood of survival of that patient at one year, 93% of family and caregivers thought that their loved one would be alive at one year.
00:32:29
Speaker
They felt that they would be back to their functional state at one year.
00:32:33
Speaker
and they thought that they would have a good quality of life 83% of the time.
00:32:39
Speaker
When you compare that to what the clinicians caring for that same patient thought, you can see that there's a big, big discrepancy and a misalignment in terms of overall prognosis.
Family Expectations vs Clinician Prognosis
00:32:52
Speaker
What was very interesting about this study was that at one year, only 9% of the patients were alive and home without significant impairment.
00:33:04
Speaker
So a very small percent of patients actually made it to a meaningful recovery.
00:33:10
Speaker
But what was also very telling about this study was that only 25 percent of the family members interviewed, so one in four reported that they actually had a discussion about survival, what to expect in terms of care,
00:33:30
Speaker
and what to expect in terms of quality of life for their loved one with the physicians.
00:33:35
Speaker
So clearly, this study identified two very powerful problems.
00:33:41
Speaker
Number one is a lot of decisions are made based on unrealistic expectations from family.
00:33:51
Speaker
And number two, as clinicians, we are not sharing with families meaningful information
00:33:58
Speaker
in terms of survival, functional status, what does it entail caring for this patient, what happens to patients in a similar situation, which I think is important if we really want to provide patient-centered care and if we want to provide appropriate goals of care that are aligned with what each patient and their family wants for their own healthcare.
00:34:21
Speaker
This is a large meta-analysis by Emily Daymuth and collaborators
00:34:29
Speaker
looking at the long-term survival of critically ill patients treated with prolonged mechanical ventilation.
00:34:34
Speaker
And they really did an excellent job of really reviewing the vast literature, qualifying all the studies available.
00:34:42
Speaker
And what they found is that from the studies that they ultimately kept, 42 in total, the average age was around 64.
00:34:50
Speaker
So these were not necessarily young patients.
00:34:54
Speaker
44% were female.
00:34:56
Speaker
and their Apache 2 scores were around 19.
00:35:00
Speaker
When you look at the outcomes of these patients, what they found is that 29% of the patients had a mortality in-hospital mortality.
00:35:10
Speaker
So a third of these patients died in the hospital, necessarily in the ICU.
00:35:15
Speaker
But when you looked at one year of survival, or mortality, sorry, 62% of them were dead.
00:35:22
Speaker
So at one year, more than half of the patients
00:35:25
Speaker
of this large meta-analysis died with prolonged mechanical ventilation.
00:35:31
Speaker
19% of the overall cohort were able to get home and 50% were discharged.
00:35:36
Speaker
Now, I think that these are numbers that are important to share with families so they understand what their loved ones are looking at.
00:35:45
Speaker
Individual cases obviously do not necessarily conform to an average, but I think that if people understood what is likely to happen to their loved one
00:35:55
Speaker
they might be in a better position to make a decision that is aligned with the goals of care that that patient would have wanted.
Survival Rates in Prolonged Ventilation Cases
00:36:03
Speaker
So this is a very, I think, important study for this field and really, I mean, compiles data from many, many studies in the literature.
00:36:14
Speaker
What about predicting the mortality of those patients who already have prolonged mechanical ventilation?
00:36:20
Speaker
So this is a very interesting study.
00:36:22
Speaker
It's a multi-institutional study.
00:36:24
Speaker
study that was basically looking at, at the time of tracheostomy, you could actually predict the mortality or the survival of these patients based on a very simple scoring system called the PROVENT score.
00:36:41
Speaker
And basically, as you can see, you have five categories, age equal over 65, age 50 to 64,
00:36:51
Speaker
platelet count below 150, vasopressor presence, and hemodialysis.
00:36:55
Speaker
And for each one of these, you assign the given points, and then what you can see is that for those patients who had more than two points, the likelihood of surviving was only 25%.
00:37:08
Speaker
So clearly, these patients are sick, and they have a very low likelihood of survival at one year.
00:37:15
Speaker
And I think, again, this can be information that is helpful for families in deciding
00:37:20
Speaker
what the next step would be in terms of providing care.
00:37:24
Speaker
Those patients who had four or more of these actually had almost 100 percent mortality short term.
00:37:34
Speaker
So again, I think something to think about and more information that we can use to discuss with our families as we make these decisions.
00:37:44
Speaker
So we talked about prolonged mechanical ventilation
00:37:48
Speaker
from a very broad perspective, let's focus a little bit more in terms of Mr. Johnson, who might be a typical patient.
00:37:56
Speaker
And a lot of what so far has determined prolonged mechanical ventilation or the duration of mechanical ventilation has been attributed to patient factors, severity of disease, what is the disease, and other factors.
00:38:12
Speaker
But what we know is that if Mr. Johnson
00:38:16
Speaker
If we had several clones of Mr. Johnson admitted to different hospitals, what we would know is that more likely than not, his trajectory would be influenced by the process of care where somebody washed their hands or didn't wash their hands and gave them an infection, where somebody did the proper sedation and did holiday sedations and SPTs, where somebody worked on
00:38:43
Speaker
getting him out of bed while he was in the ventilator, et cetera, et cetera.
00:38:47
Speaker
And what you can see is that there's a whole host of events here, the acute phase of mechanical ventilation, when we decide to do a trach, doing the trach, the mechanical ventilation portion on the trach, weaning off mechanical ventilation, death itself, and ultimately discharge alive.
00:39:03
Speaker
And what you'll see is that there's tremendous variability in all these events.
00:39:08
Speaker
And not only is there variability from hospital to hospital, but I think that there might be variability
00:39:13
Speaker
within a hospital in terms of how this is practiced on a daily basis.
00:39:18
Speaker
So the question is, what can we do to bend this curve on these super users and on these prolonged mechanical ventilation patients?
00:39:26
Speaker
And I think it's good to come back to our original equation of value in terms of outcomes and in terms of cost.
00:39:35
Speaker
So in terms of outcomes, I believe that probably the single most valuable approach
00:39:42
Speaker
to driving or improving outcomes in patients in the ICU, but definitely those who are on mechanical ventilation, is the implementation of the ABCDEF bundle.
00:39:54
Speaker
And as many of you are aware, because you're probably doing either some elements or all these elements in your ICUs, the A stands for Assess, Prevent, and Manage Pain, the C for both the spontaneous awakening trial and the spontaneous breathing trial, so the holiday
00:40:11
Speaker
sedation holiday and the SPT.
00:40:14
Speaker
C for the choice of analgesia and sedation following the PAD guidelines.
00:40:19
Speaker
And this is really taking us away from benzodiazepine rips, which are still utilized in many places, but have clearly been associated with worse outcomes in these patients.
00:40:30
Speaker
D stands for delirium, assessing, preventing, and managing.
00:40:34
Speaker
Now, unfortunately, we don't have tools to treat delirium effectively.
00:40:40
Speaker
but there's clearly ways of identifying it and there's ways of preventing it that might be very, very important.
00:40:48
Speaker
E is for early mobility and exercise.
00:40:50
Speaker
This whole concept of getting people on the ventilator up and standing and walking as soon as possible, even while they're on the ventilator.
00:40:58
Speaker
And finally, F is for engaging families and empowering them to be part of the process of care.
00:41:05
Speaker
When I was in training,
00:41:06
Speaker
If families would have to wait outside the ICU, would be allowed to come in and visit for very short periods of time, today they participate in RALM, they participate in care, and I think it's an important, important aspect of helping these patients recover as soon as possible to empower and include families in the care of these patients.
00:41:26
Speaker
So some data on the ABCDEF bundle, this is one of the first large studies that the
00:41:33
Speaker
and the consortium did at seven community hospitals in California.
00:41:37
Speaker
And what you can see is the top two slides look at total bundle compliance, so basically it was all or nothing.
00:41:45
Speaker
So are you doing all the elements of the bundle or not?
00:41:48
Speaker
And as the number of the proportion of patients increases, what you can see is that the survival in the hospital improves.
00:41:56
Speaker
On average, for every 10% improvement in the number of patients who get the whole bundle,
00:42:02
Speaker
there's a 7% reduction in the risk of death or a 7% improvement in survival.
00:42:08
Speaker
Same thing with looking at brain function and looking at delirium and comma-free days.
00:42:14
Speaker
As you improve performance of all or nothing of the bundle, you get a significant improvement in the lack of delirium and comma-free days for these patients.
00:42:27
Speaker
Now, underneath, we have what happens when you just use some elements of the bundle.
00:42:32
Speaker
And again, what they wanted to show was that an increase in the number of elements being applied, and you even have a more robust curve that is associated with improved hospital mortality and improved delirium and comma-free days.
00:42:47
Speaker
And what this illustrates is two things that are very important.
00:42:50
Speaker
Number one, that applying the A to F bundles improves outcomes.
00:42:56
Speaker
And number two, that it improves outcomes in a dose-response way.
00:43:02
Speaker
which means that if you're not doing anything, whatever you start doing will improve outcomes and as you do better and more, that improvement will continue to rise.
00:43:11
Speaker
And I think it's important for people to stay humble with the ATF bundles because a lot of people say, oh, we're doing it, but I can guarantee you that if you really think of this dose response, there is probably still opportunity for you to improve the dose and the effectiveness of what you're doing by improving each aspect of what you're doing further.
00:43:31
Speaker
So clearly you could be working on the ABCDF bundle for years to come and there will still be opportunity to keep driving outcomes in the right direction.
00:43:41
Speaker
This is the second study or larger study that was published earlier this year looking at 15,000 ICU patients that utilized the ICU Liberation Collaborative bundles.
00:43:51
Speaker
And again here you can see that the proportion of bundle elements that were performed as it increases
00:43:58
Speaker
you have an increase, significant increase in discharge from the ICU, significant increase in discharge from the hospital, so going, I mean, back home, and a significant decrease in the likelihood of dying in the ICU.
00:44:10
Speaker
So all, I think, very important patient-centered outcomes.
00:44:15
Speaker
Additionally, you can see that as you increase the percent, you decrease days of mechanical ventilation, you decrease the likelihood of coma, delirium, the use of physical restraints,
00:44:26
Speaker
Of interest is you do increase the referral of pain.
00:44:30
Speaker
And I do think that this is related mostly to these patients being more active, more awake, and being able to tell us that they're in pain.
00:44:37
Speaker
But overall, clearly, all the outcomes driven in the right direction really showing that the implementation of these ABCDF bundles improve patient-important outcomes but also have a dose-response type of effect.
00:44:53
Speaker
which really encourages people to start and keep working on improving.
00:44:58
Speaker
The second portion of this value equation is cost.
00:45:02
Speaker
So what can we do for cost?
00:45:04
Speaker
This is a paper that was published some years ago.
00:45:07
Speaker
This is work that I had the opportunity to do with Steve Triziak and our colleagues, where we really focused on these ProLon Mechanical Ventilation super users with the idea of trying to decrease variability
00:45:22
Speaker
of certain events and processes that we thought were critical in moving these patients forward.
00:45:28
Speaker
And the idea was to apply a Lean Six Sigma approach to decreasing variation and identifying where we could create value and decrease waste.
00:45:36
Speaker
So these are some of the important discussions that we've done.
00:45:40
Speaker
And really the idea was that if we standardized the way we interacted with families and the information that we shared, we could compress the timeframe of making decisions and getting patients
00:45:52
Speaker
either trached, extubated, or moving along to a long-term weaning facility.
00:45:58
Speaker
And what you can see is that in a small number of patients, this total of 259 patients, we basically, in a pre and post model, were able to decrease the hospital length of stay, which was the primary outcome, by around 25%.
00:46:13
Speaker
So from an average of 29, a medium of 29 days to a medium of 22 days.
00:46:20
Speaker
And in terms of costs, direct costs, that represented a decrease in caring for these patients from $66,000 per episode to $48,000.
00:46:35
Speaker
And those cost savings, when you multiply them by the number of patients, really gave a big number of savings for the hospital.
00:46:43
Speaker
So by focusing on 100-plus patients,
00:46:46
Speaker
you could actually save a little bit over $2 million, which is really remarkable from a cost perspective.
00:46:52
Speaker
And the idea here being that we are standardizing the processes that lead to decision-making and information with our family members and these patients who are on the ventilator who, as they become prolonged mechanical ventilation, we've identified very early.
00:47:07
Speaker
So what we propose today is that you think about these patients in terms of maybe four big timeframes.
00:47:16
Speaker
There's the acute ventricular management, which really goes from the time they get intubated to day four or five.
00:47:21
Speaker
Then there's a decision to make the tracheostomy, which usually should start around day five to seven.
00:47:27
Speaker
And we are not saying that you should trach everybody on day seven, but by day seven, if you've done all the right family communications and discussions, you can actually have a plan for when you're going to trach them.
00:47:40
Speaker
Then the tracheostomy itself, which usually occurs between day seven and ten,
00:47:46
Speaker
And then there's the post-trach management to discharge, which really starts after the tracheostomy.
00:47:51
Speaker
And the idea is to continue weaning the patient, but also to move them to the right site of care as soon as possible.
00:47:59
Speaker
Now, when you look at this, there's really a couple of very important family meetings.
00:48:05
Speaker
So there's three family meetings that are very important, and we have categorized them as the 24-hour family communication, which is in the first 24 hours,
00:48:16
Speaker
There should be a documented conversation with families where we basically explain what's going on, set expectations for potential hospital course, identify all points of contact for decisions, identify the patient wishes.
00:48:30
Speaker
I mean, some patients might have very clear wishes of what they want and don't want, and in those patients, maybe a tracheostomy or prolonged mechanical ventilation would be inappropriate or misaligned with their wishes.
00:48:41
Speaker
And then at the same time, introduce family
00:48:44
Speaker
to case management and social workers so that they know that there's a team of people working with them and that this might require more than just an acute hospital stay in the ICU.
00:48:55
Speaker
What we found is that if somebody's on a ventilator by day five, the likelihood that they will need some sort of post-acute care is significantly increasing.
00:49:05
Speaker
So at this point, give patients family updates
00:49:10
Speaker
really start introducing the concept that this patient may need a tracheostomy.
00:49:14
Speaker
We're not making decisions, we're just introducing the idea so they can ask the right questions, start thinking about, readdress the goals of care.
00:49:21
Speaker
In some patients, it might be very appropriate at this point to involve supportive care or palliative medicine if that's what the family and the patient would want for their goals of care.
00:49:33
Speaker
So again, I think it's an opportunity to have a structured conversation with the family members.
00:49:38
Speaker
And then by day seven,
00:49:40
Speaker
the family should already be tuned into what's going on clinically, the need for a tracheostomy, the need for post-acute care.
00:49:48
Speaker
And at this point, maybe it's a good time to outline what the plan would be for tracheostomy.
00:49:53
Speaker
Sometimes the plan might be we failed three times with the weaning, we should go ahead and do the trach.
00:49:58
Speaker
Or it might be we're going to try weaning one or two more times based on these changes and see if we can get them extubated.
00:50:04
Speaker
Or it might be the patient never wanted a trach.
00:50:07
Speaker
And maybe we're talking about compassion extubation
00:50:09
Speaker
or other alternatives.
00:50:10
Speaker
But the idea really is by standardizing these three touch points at 24 hours, five days, and seven days, you can compress the variation that occurs between providers and among one single provider and really drive the care of these patients further and make sure that we are making decisions in a timely fashion.
Value-driven Focus on Prolonged Mechanical Ventilation
00:50:33
Speaker
So we covered the idea of outliers
00:50:38
Speaker
super users or hotspotters and prolonged mechanical ventilation and how they all fit together into what today is value-driven medicine.
00:50:46
Speaker
We talked about prolonged mechanical ventilation as that particular hotspotter population in our ICUs that we could be focusing on as opposed to just treating as outliers in our data.
00:50:58
Speaker
And really, even though they're a small group of patients, we now understand that they consume an enormous amount of resources and that there's a lot of
00:51:06
Speaker
prognostic information that we're not sharing with families that should be part of discussions to really understand what is the best way to move forward with these individual patients.
00:51:16
Speaker
And finally, we talked about how we could look at value from both improved outcomes and cost and target two very concrete pathways, one through the A, B, C, D, F bundles and really driving and implementing those in our ICUs to improve patient outcomes, especially when they're on the ventilator.
00:51:36
Speaker
And two is how we can utilize standardized approaches to decrease the variation and compress the timeframe of how we make decisions and communicate with families to drive length of stay down and really manage the cost of these patients.
00:51:52
Speaker
So if you have any questions, feel free to text them in.
00:51:56
Speaker
What we'll do now is we'll go to the second part of our webinar and have a conversation with John D'Ambrosio,
00:52:02
Speaker
who's a colleague of mine.
00:52:03
Speaker
He's our program medical director at St.
00:52:05
Speaker
Francis in Delaware and has also been working and interested in this particular problem in his ICU.
00:52:12
Speaker
John, how are you?
00:52:13
Speaker
Welcome to the webinar.
00:52:15
Speaker
Thanks, Sergio.
00:52:16
Speaker
Doing well.
00:52:17
Speaker
So I know that you have embarked in these hotspotters in the last 18 months, 12 months, really focusing on this.
00:52:27
Speaker
And as I recall, because of conversations we had in the past,
00:52:31
Speaker
You would always talk about these patients, but you'd always say, well, it's a small number of patients.
00:52:34
Speaker
But I think that eventually it became very clear to you that even though it's a small number of patients, they do consume an enormous amount of resources.
00:52:42
Speaker
And when you presented your ideas to the hospital, I think they were received with a lot of interest.
00:52:49
Speaker
And maybe you share with us what you've done at your shop.
00:52:53
Speaker
Sure.
00:52:54
Speaker
So you first introduced this concept to me, and I heard this similar lecture from you.
00:53:01
Speaker
and presented the data in 2018.
00:53:03
Speaker
And every quarter we go through our quarterly performance review and report our data out.
00:53:10
Speaker
And then every quarter I report my data with and without the outliers as they can, you know, in a small hospital or a 10 bed ICU can really affect the data significantly.
00:53:23
Speaker
One or two extra patients can really kind of move things in the bad direction.
00:53:28
Speaker
So, and every time you tell me, John, you got to look at those outliers.
00:53:32
Speaker
And so I remember this lecture and, you know, obviously we're always trying to, you know, improve value in our hospital.
00:53:40
Speaker
And by reducing the length of stay and cost of care of these patients, I decided to start this initiative.
00:53:45
Speaker
I introduced it to the C-suite and beginning of the year.
00:53:50
Speaker
And the CMO really, as soon as I said it, his eyes kind of
00:53:54
Speaker
popped open said that that is a great idea I think that'd be really interesting and Immediately, you know, I referred back to that Six Sigma black belt article to see how you went through this process and talk to you and You know I saw that all the different steps that you took and I identified the major source major variation in practice as being the physicians and the timing of the tracheostomy as you
00:54:26
Speaker
provided all that information here.
00:54:29
Speaker
You know, when one physician comes in, the next physician comes in, sometimes they want to get the, they want to get comfortable with the patient, see the patient multiple times before making these decisions.
00:54:40
Speaker
But clearly there's a, you know, we have to standardize this practice.
00:54:45
Speaker
And so what I did was I, like you said, had three family meetings scheduled, day one, day five, and day seven.
00:54:54
Speaker
And
00:54:55
Speaker
My goals, just as you laid out in that diagram, the day one is just to introduce the family to the team, discuss goals of care, discuss what mechanical ventilation is and what's going on with their loved one.
00:55:09
Speaker
And then obviously the family would be on rounds if they desired and they would have updates.
00:55:14
Speaker
But the day five conversations, really the point of that day five conversation, as you said, was to introduce
00:55:25
Speaker
the tracheostomy and, you know, go through everything in detail as far as what's going on with their loved one, but introduce the concept of tracheostomy and provide the data as far as one year mortality, 30 day mortality prior to discharge and likelihood to be weaned off the ventilator and likelihood to go home.
00:55:47
Speaker
So to provide some of that data to the family and, um,
00:55:52
Speaker
and then kind of revisit in day seven to see if the family would like to have a tracheostomy.
00:55:57
Speaker
So like I said, there was some variation from position to position.
00:56:02
Speaker
And what I did was I met with a team, met with a respiratory therapist, social work, the RNs, in-practice guidelines, to discuss that we need these family meetings and to have some kind of backup.
00:56:17
Speaker
if you will.
00:56:18
Speaker
So on rounds, a respiratory therapist will say it's day four, day five of mechanical ventilation.
00:56:24
Speaker
Social work will automatically now, any mechanically ventilated patient we have, she'll tell me or he will tell me that it's day five of mechanical ventilation, I want to schedule a family meeting.
00:56:37
Speaker
So we have all these kind of backups just in case there's a new physician coming in, just coming on service, and he's seeing a patient, and we also have it on sign out too.
00:56:47
Speaker
what day of mechanical ventilation the patient is actually on.
00:56:50
Speaker
So we don't kind of miss that mark.
00:56:53
Speaker
And I think that something, and we'll talk about some of your outcomes in a second, but I think that clearly, obviously, a lot of the focus of the initiative of looking at super users is based on improving outcomes, but there's also an important cost component
00:57:14
Speaker
And the biggest driver of cost for these patients is their length of stay in the ICU and in the hospital because that's where they consume the most amount of resources.
00:57:22
Speaker
So obviously being able to move them along to a lower level of care does improve costs.
00:57:29
Speaker
But I also think that from a patient experience, what I have found, and I want to hear your thoughts, John, is that by
00:57:40
Speaker
forcing us to talk or by reminding us to, by prompting us, right, that nudging of talk on day 20, in the first day, talk on day five, talk on day seven, you're actually probably discussing more than we think we usually discuss with patients and families and providing them with more useful information that ultimately, whatever the decision is, I think improves their experience with that hospital stay and it's probably an important quality indicator as well.
00:58:07
Speaker
Could you comment on that?
00:58:11
Speaker
Yeah, I think, you know, going through this process, we haven't seen an increased number of tracheostomies.
00:58:19
Speaker
And I think the family is relieved.
00:58:22
Speaker
Like you said, there's a big disconnect between the physician and the family as far as expectation.
00:58:28
Speaker
And actually, how many family members are getting this information of survival and prognosis?
00:58:36
Speaker
Obviously, when a patient is going through, when a patient is
00:58:42
Speaker
has prolonged mechanical ventilation.
00:58:44
Speaker
They're very sick.
00:58:46
Speaker
And so I do feel like, you know, communication does build some trust with the family and they feel comfortable, you know, with you.
00:58:59
Speaker
And in the end, you want them to feel like you're doing everything for them.
00:59:05
Speaker
And I will emphasize that.
00:59:06
Speaker
Day five, you know, I'm just introducing this concept.
00:59:09
Speaker
But I'm still trying to get your loved one off the ventilator.
00:59:12
Speaker
Something changes.
00:59:13
Speaker
We can certainly, you know, extubate them or get them off the ventilator.
00:59:18
Speaker
But we're going to put the consult in on day seven.
00:59:21
Speaker
My goal is to perform a tracheostomy by day eight or ten, eight to ten.
00:59:26
Speaker
So, yeah, I do feel like they have.
00:59:30
Speaker
They're more comfortable with that.
00:59:33
Speaker
And I think that there's other aspects, obviously, that are associated with that.
00:59:37
Speaker
I mean, I think that the family meetings, as simple as it sounds, I mean, the more you get it hardwired, I think the more you move the needle.
00:59:45
Speaker
But obviously, that is associated also with at the same time during rounds implementing the ABCDF bundles, moving that forward, early mobility, getting patients on the right station, off sedation.
00:59:56
Speaker
Those are all things that are very important.
00:59:58
Speaker
And I think that we shouldn't disregard that aspect of care as well.
01:00:03
Speaker
The other thing that we didn't talk about, John, and I think is important, and that might be very center-dependent, is that another way of thinking of cost is current recommendations would push patients towards bedside percutaneous tracheostomies in the ICU as opposed to OR open tracheostomies.
01:00:22
Speaker
And standardizing how the tracheostomies are done at each institution is also another way of trying to decrease the cost and I think is also important.
01:00:33
Speaker
Any comments on the tracheostomy itself?
01:00:35
Speaker
I mean, have you experienced, I think it's always perceived as a challenge to get tracheostomies in some institutions, but when you really look at what really the variation is, it's our decision making to get to that tracheostomy.
01:00:48
Speaker
Any comments on your experience in this, John?
01:00:51
Speaker
Yes, it does take some time.
01:00:55
Speaker
Our hospital is a small hospital.
01:00:57
Speaker
We have ENT and surgeons and
01:01:00
Speaker
but they prefer to do the tracheostomy in the OR.
01:01:02
Speaker
So you need OR time, they have to clear their schedule.
01:01:06
Speaker
So it will take two or three days at least to get things kind of scheduled and laid out.
01:01:12
Speaker
And I don't like a surgeon to clear his schedule and then cancel a tracheostomy, but sometimes it does happen and they're aware of that.
01:01:25
Speaker
But yeah, it is a little bit of a challenge in my facility to get that tracheostomy.
01:01:28
Speaker
That's why it's important by day seven that we kind of have a general idea, have an idea exactly what the family would like to do as far as regarding that procedure.
01:01:39
Speaker
Absolutely.
01:01:40
Speaker
Can you share with us a little bit maybe of what you have found as you've implemented this in terms of first time, maybe challenges that you found, I mean, with other medical staff, I mean, or with other
01:01:51
Speaker
ICU team members and then maybe what are some of the results that you've driven that you think are positive?
01:01:59
Speaker
I think the challenge still is the communication piece because there's, you know, and like I said, you have to emphasize just the entire team, RN, social work, respiratory physicians, because there's still that, you know, that there's still some people that say you have up until 14 days to make a decision for tracheostomy.
01:02:20
Speaker
So now a day for, you know, families have it in their head.
01:02:22
Speaker
By day 14, I have to make that decision.
01:02:25
Speaker
And I sometimes I will come into play when I talk with him.
01:02:30
Speaker
And so I just want the whole team to be on the same page when we when we communicate with family.
01:02:34
Speaker
So that's been an obstacle a little bit.
01:02:37
Speaker
As far as my outcome, Sergio, the first quarter of this year, 14 percent of my patients on mechanical ventilation were over seven days and they represented 46 percent of my vent days.
01:02:51
Speaker
The following two quarters, it was about 10%.
01:02:53
Speaker
It was 10% of my patients had prolonged mechanical ventilation.
01:02:58
Speaker
And with scheduling these family meetings and standardizing this discussion with family, those vent days at 10% represented 25% of our ventilation days.
01:03:11
Speaker
With the overall reduction of our ICU length of stay of 20% and our hospital length of stay of 24%, which just so happens to be the same
01:03:22
Speaker
outcome that you actually published in your study in Six Sigma Black Belt.
01:03:26
Speaker
But yeah, so we've had a significant reduction in ICU length of stay and hospital length of stay.
01:03:32
Speaker
And sometimes this conversation happening earlier will, family will make that determination and they may just say, you know, we don't want the procedure.
01:03:42
Speaker
We prefer not to do it.
01:03:43
Speaker
We're going to consider hospice.
01:03:45
Speaker
And, or they need a little bit more time, but at least things are started and laid out earlier.
01:03:51
Speaker
And I think that you just pointed out at a very important aspect of this that, again, I think speaks to value, right?
01:03:58
Speaker
So it's very unfortunate when a patient who's not a good candidate for a tracheostomy or who might not even have wanted a tracheostomy ends up getting a tracheostomy, a prolonged course in the hospital or an LTAC, and they still has a horrible outcome.
01:04:16
Speaker
And then families usually say, well, I would have known it was like that.
01:04:19
Speaker
I wouldn't have done it, right?
01:04:20
Speaker
So I think that a big part of this also is by standardizing these conversations is identifying those patients who might not be appropriate for a tracheostomy, where the family with the right information can identify this is not aligned with what my loved one wants at this stage in their life for their care.
01:04:40
Speaker
And that is a saving that is very hard to quantify, but it is very real, right?
01:04:45
Speaker
Because you are avoiding unnecessary care, which is one of the most
01:04:50
Speaker
important drivers of increased cost in our healthcare.
01:04:55
Speaker
So I think that, again, I mean, both from a value perspective in terms of providing better patient outcomes and experiences, but also driving cost, that aspect or those patients are very, very important.
01:05:07
Speaker
Have you found that maybe anecdotal?
01:05:10
Speaker
I don't think the numbers allowed you to look at this in terms of numbers, but you have identified, you think, John,
01:05:16
Speaker
more families that with the right information now are saying this is not what my loved one would want.
01:05:20
Speaker
What is your experience with this aspect of this thematic?
01:05:26
Speaker
That's a great point, Sergio.
01:05:28
Speaker
I've had that experience many times.
01:05:29
Speaker
We have an LTAC in our hospital and we do get patients from the LTAC quite frequently.
01:05:37
Speaker
And I will talk to those family members.
01:05:41
Speaker
You know, most of the time they are trached and prolonged mechanical ventilation patients.
01:05:46
Speaker
And so I will introduce that, you know, he family members very sick.
01:05:50
Speaker
These are the issues that are going on.
01:05:52
Speaker
And obviously they're getting sicker.
01:05:53
Speaker
They had to be transferred to the ICU.
01:05:55
Speaker
And I'll provide that data of, you know, patients with tracheostomy in general have a 60% mortality in one year.
01:06:03
Speaker
And I'll go through that and they will tell me, you know, I never knew that information.
01:06:09
Speaker
I probably would not have done this if I knew that they, you know, that,
01:06:14
Speaker
they would, their mortality is so high or they're unlikely to survive the hospitalization, especially when you add other, you know, comorbidities, you know, with severe cardiomyopathy, renal failure, all these other things on top of the tracheostomy.
01:06:30
Speaker
So, yeah, talking to family and going through those things, I think, like you said, I do think there's a big disconnect with communication to family prior to having this procedure done.
01:06:41
Speaker
Absolutely.
01:06:42
Speaker
And I do think that, again, I mean, what I would suggest, I mean, to all our listeners is that if they are tracking duration of mechanical ventilation, which I'm sure they are, the next time they think of these patients on a prolonged mechanical ventilation path as just outliers to maybe refocus and say, okay, there are things that we can do specifically for that population.
01:07:04
Speaker
And I think, like you said, I mean, you've seen the same thing.
01:07:07
Speaker
Small number of patients, large amount of resources.
01:07:11
Speaker
Some systems have actually quantified this just from a cost perspective.
01:07:15
Speaker
And in one large multi-hospital system, I saw data that these patients constituted 1% of their population, yet it was almost 10% of their total cost of care.
01:07:26
Speaker
So really, a disproportionate amount of resources from a cost perspective.
01:07:30
Speaker
And I think from an outcome perspective, by focusing on the A to F bundles early on,
01:07:37
Speaker
I think we can achieve better outcomes, which is really getting patients back to a functional state as soon as possible and liberating them from the
Implementing the ABCDEF Bundle in ICUs
01:07:44
Speaker
ICU.
01:07:44
Speaker
But also by having these conversations in a systematic and organized way, I think we will provide better information to families to make better decisions that are aligned with the care that they want for their loved ones.
01:07:57
Speaker
And in many cases, avoiding unnecessary care, I think, would be a big plus for the patient.
01:08:05
Speaker
What are your, any final thoughts, I mean, John, in terms of what you recommend people who are interested in this or any final thoughts in terms of what you have learned from this whole experience?
01:08:16
Speaker
I think it's a easy win, to be honest with you.
01:08:21
Speaker
I think, like you said, preventing unnecessary procedures, implementing the A through F bundle, and having these family meetings is, I think they're all tied together.
Importance of Structured Family Meetings
01:08:32
Speaker
And, um,
01:08:34
Speaker
You know, I would just say, you know, obviously get some baseline data and then, you know, just follow your data here, your slides, your template that you already laid out.
01:08:45
Speaker
Mine is meet with family on day one, five and seven and discuss how these family meetings to discuss the plan of care and include your entire team and go from there.
01:09:01
Speaker
Excellent.
01:09:02
Speaker
So I think that we'll stop here.
01:09:05
Speaker
And thank you so much, John, for sharing your experience with us.
01:09:09
Speaker
For our listeners, we hope that this was something that you can adopt or use, I mean, if you're already doing something similar.
01:09:16
Speaker
And we look forward to our next clinical webinar.
01:09:19
Speaker
John, thank you so much for your time.
01:09:22
Speaker
Thank you, Sergio.
01:09:25
Speaker
Thank you for listening to Critical Matters, a Sound Critical Care podcast.
01:09:29
Speaker
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01:09:35
Speaker
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01:09:40
Speaker
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