Keep Calm and Stay Out of the ICU: A Comprehensive Approach to Reducing Unplanned ICU Admissions

General Information 

Institution Name: Geisinger Community Medical Center

Submitter Name and Title: Brian Frank, MD, FACS, Assistant Trauma Medical Director; Ann Lewis, RN, BSN, Trauma PI Integration Specialist; Joan Magnotta, RN, Performance Improvement/Care Manager; Chris Guzzi, Trauma Registrar; Deb Clark, RN, BSN, Trauma Program Manager; John Mitchell, MD, FACS, Trauma Medical Director

Name of the Case Study: Keep Calm and Stay Out of the ICU: A Comprehensive Approach to Reducing Unplanned ICU Admissions

What Was Done? 

Global Problem Addressed 

Unplanned intensive care unit (ICU) transfer is implicated as a harbinger of morbidity and mortality in hospitalized patients. This specific event has been attributed to in-hospital mortality rates of 18 to 25 percent when compared with a population not requiring unplanned transfer, a mortality rate that can be three times greater.^1-2 Furthermore, it increases hospital length of stay and hospital costs.^1-4 As such, attention is paid to appropriately identify patients requiring a higher care level on admission and early intervention in deteriorating patients. The Joint Commission has named this occurrence a target to improve quality.¹ Many societies, trauma included, have offered ICU-suggested admission criteria.

For many, these guidelines are obviated by the need to deliver specialized care only available in an ICU (in other words, mechanical ventilation). For other patient cohorts, the decision is more nuanced.³ Prior studies identified acute respiratory failure, respiratory insufficiency, increasing oxygen requirements, and tachypnea as common diagnoses for transfer.^1-5 Additionally, many reports have attributed the need for transfer to medical error, including triage error.^1,3-4 Rib fracture populations are one such group especially vulnerable to unanticipated transfer because of progressive respiratory failure and difficulty in triaging these patients. There are several scoring systems available to help predict clinical deterioration, but it would seem the most important approaches include appropriate triage on admission and an effective protocol to optimize care.^6-8

Identification of Local Problem 

In our initial Trauma Quality Improvement Program (TQIP) report (Spring 2017), we were a high outlier for unplanned ICU admission with an OR of 1.83. As a result, we performed an in-depth chart review of all patients transferred to the ICU the prior year. We identified 2 percent of our trauma patients met this criterion. Of these patients, 80 percent had developed respiratory failure secondary to rib fractures requiring further interventions in the ICU, including 75 percent of those patients requiring intubation. There was no guideline driving clinical decision-making for admission level of care or uniformly addressing patient needs or follow-up once admitted. The physician discretion approach resulted in unacceptable rates of transfer and unnecessarily exposed our patients to risk of morbidity, mortality, increased length of stay, and increased cost.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Geisinger Community Medical Center (CMC) is a community-based, 300-bed, Level II trauma center within an integrated health network. The trauma team serves six mainly rural counties in northeast Pennsylvania. The service cared for 1,900 patients last year.

There was no direct hospital oversight, but the health system has prioritized the Centers for Medicare & Medicaid Services (CMS) Five-Star rating system. As such, support from respiratory therapy and nursing leadership was provided in an effort to decrease length of stay and mortality as they relate to unplanned ICU transfer.

Planning and Development Process 

Anecdotally we had identified the need for intubation as a driving factor for the need to transfer to the ICU. In conducting our patient review, we utilized data from our Pennsylvania Trauma Outcomes Summary (PTOS). Our performance improvement (PI) team identified common factors believed to result in decompensation. These included more than three rib fractures, age >65, history of smoking, bilateral rib fractures, pulmonary complication (acute traumatic, such as pneumothorax, or historical, such as history of COPD), and immobility related to other injuries. These factors were targeted based on prior scoring systems and weighted against our population of interest. Each factor was given equal weight (score of 1). Utilizing this triage system, we were able to accurately predict decompensation if a score is 3 or higher. Our PI team then internally validated the scoring system using 2015 PTOS data. The scoring system was able to accurately predict more than half the patients with clinical demise.

Triaging patients appropriately would prove to be only part of the equation. Prior evidence supports 48 to 76 percent of patients go on to clinical deterioration.^1,3 As such, our physician and advanced practitioner team devised a protocol focusing on multimodal pain control and short interval follow-up with a specific focus on respiratory parameters. We engaged nursing and respiratory therapy to help assess and alert for early physiologic changes, such as poor pain control, worsening vital signs, or decline in incentive spirometry (IS). We utilized an aggressive education approach and real-time chart review to audit compliance.

Description of the Quality Improvement Activity 

As a result of data compiled to define the problem, we focused efforts on addressing three key parameters: appropriate triage, effective multimodal pain control, and restoring and maintaining normal physiology. A new rib fracture protocol was introduced. The trauma director and senior advanced practitioner were responsible for educating team members. PI staff who were actively engaged with the development of the scoring system were also instrumental in ensuring understanding and compliance with the new triage criteria. Nursing leadership was included in the education, as patients would now be more aggressively triaged to a higher level of care based on risk factors.

Once admitted, patients were prescribed a multimodal pain regimen that included acetaminophen, ibuprofen (if clinically appropriate), local anesthetic (dermal lidocaine), muscle relaxant, and short-acting narcotics. Adjunctive agents, including gabapentin, clonidine, or others were selectively used based on patient reports of pain. Patients were prescribed nebulizers to optimize pulmonary hygiene and were given respiratory therapy-directed instruction on IS use. Patients were expected to achieve 80 percent of predicted based on age and height per the IS nomogram provided. Patients who failed to achieve this target or fell below this target were triaged to more aggressive pulmonary interventions prior to transfer. Attention was paid to more invasive pain control, including IV narcotics, IV lidocaine, or epidural catheter placement. Patients who were still unable to meet this threshold were considered for ICU transfer and/or operative rib fixation, if appropriate.

With respect to pulmonary hygiene and physiology, we quickly identified challenges with respect to IS understanding and use. We enlisted the help of nursing and respiratory therapy to design an educational tool to share with patients to help them understand and track the appropriate use of the device. Nursing documentation of IS in the electronic medical record (EMR) was expected every four hours despite more frequent use. Common pitfalls were the spirometer was often moved outside arm’s reach of the patient, and new staff were unfamiliar with how to identify a predicted.

Resources Used and Skills Needed

Staff 

Protocol development and education included three physicians and two advanced practitioners. Two PI integration specialists were instrumental in identifying risk factors to help inform the scoring system. We included one respiratory therapy lead and two PI care managers to help with training staff and real-time chart review. 

Costs

There were no additional costs beyond routine care. 

What Were the Results?

Overall Results 

Complete protocol development, “go-live,” and implementation took approximately 12 months. We introduced each step incrementally, first focusing on appropriate triage, next on multimodal pain control, and finally with pulmonary hygiene and improved documentation. Our primary outcome was rate of unplanned ICU admission. Over the course of one year, OR of unplanned transfer decreased from 1.83 to 1.21 (Fall 2018), with incremental improvement each quarter (Figure 1).

Setbacks

Due to the increase in required EMR documentation, rates of documentation compliance were initially low. Real-time chart review and engagement from clinical leaders on our trauma floor helped with improved documentation.

Cost Savings

• There were no additional costs for investment.
• We observed a 66 percent reduction in odds of ICU admission. This is approximately equivalent to 10 fewer ICU admissions. We previously identified that 75 percent of our transfers would need mechanical ventilation, and thus we would expect between four and five patients would require mechanical ventilation. Using ICU cost data from Dasta and colleagues, we estimate cost of care pre-intervention averaged $430,612 for the ICU phase of care.9 Post-intervention, by decreasing the rate of ICU admission, we estimate mean cost to be $170,801, a savings of $259,811.

Tips for Others

• Unplanned ICU admission is multifactorial. Our center found our unplanned transfers were almost exclusively the result of respiratory decompensation in patients with rib fractures. This may not hold true for other centers.
• We encourage other centers to drill down on each event to understand contributing factors in each unique population.
• To sustain this momentum, we have incorporated this review into our primary and secondary PI meetings. In our primary PI review (daily), we review the rib score to determine appropriate level of care on admission and ensure multimodal pain control. If patients are inappropriately admitted to a level of care, we resolve that immediately with early interventions or planned transfers if necessary, to optimize care prior to decompensation. We utilize the secondary PI review to ensure ongoing documentation compliance. For staff who fail to comply with documentation we have an escalation policy, including direct nursing communication to rectify the issue, secondary communication to nurse manager, and final communication to senior nursing leadership. Many issues are resolved at the primary level; most remain at the nurse manager level.
• Ongoing education with patients and staff remains the foundation for ongoing care improvements. We have incorporated lectures every three weeks for nursing staff in our high-acuity units to reinforce the importance of these initiatives and any changes that may result from our ongoing reviews.

Acknowledgments

We would like to acknowledge and thank Richard Lopez, DO; Fred Leri, PharmD; Jess Sheridan, BSN; and Wayne Williams, RRT for their instrumental work in chart review, protocol creation, and education.

References

1. Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned Transfers to a Medical Intensive Care Unit: Causes and Relationship to Preventable Errors in Care. J Hosp Med. 2011;6:68-72. 
2. Delgado MK, Liu V, Pines JM, Kipnis P, Gardner MN, Escobar GJ. Risk Factors for Unplanned Transfer to Intensive Care Within 24 Hours of Admission from the Emergency Department in an Integrated Healthcare System. J Hosp Med. 2013;8:13-19. 
3. Dahn CM, Manasco AT, Breaud AH, Kim S, Rumas N, Moin O, Mitchell PM, Nelson KP, Baker W, Feldman JA. A Critical Analysis of Unplanned ICU Transfer within 48 Hours From ED Admission as a Quality Measure. Am J Emer Med. 2016;34:1505-1510. 
4. Marquet K, Claes N, De Troy E, Kox G, Droogmans M, Schrooten W, Weekers F, Vlayen A, Vandersteen M, Vleugels A. One Fourth of Unplanned Transfers to a Higher Level of Care are Associated with a Highly Preventable Adverse Event: A Patient Record Review in Six Belgian Hospitals. Crit Care Med. 2015;43:1053-1061. 
5. Boerma LM, Reijners EPJ, Hessels RAPA, Van Hoof MAA. Risk Factors for Unplanned Transfer to the Intensive Care Unit After Emergency Department Admission. Am J Emer Med. 2017;35:1154-1158. 
6. Forkin A, Wycech J, Crawford M, Puente I. Quantification of Rib Fractures by Different Scoring Systems. J Surg Res. 2018;229:1-8. 
7. Chapman BC, Herbert B, Rodil M, Salotto J, Stovall RT, Biffl W, Johnson J, Burlew CC, Barnett C, Fox C, Moore EE, Jurkovich GJ, Pieracci FM. RibScore: A Novel Radiographic Score Based on Fracture Pattern that Predicts Pneumonia, Respiratory Failure, and Tracheostomy. J Trauma Acute Care Surg. 2016;80:95-101. 
8. Nyland BA, Spilman SK, Halub ME, Lamb KD, Jackson JA, Oetting TW, Sahr SM. A Preventative Respiratory Protocol to Identify Trauma Subjects at Risk for Respiratory Compromise on a General In-Patient Ward. Resp Care. 2016;61:1580- 1587. 
9. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily Cost of an Intensive Care Unit Day: The Contribution of Mechanical Ventilation. Crit Care Med. 2005;33:1266-127.