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“Risky States” Optimizing ICU Safety Through Patient Engagement, System Science and Information Technology Beth Israel Deaconess Medical Center; MIT; Aptima Abstract • We used existing data and expert analysis to identify fundamental risky states (risk events/event drivers) in the ICU environment, system and people in the system that impact the likelihood of risky events or actual harm to occur. • We identified corresponding harm outcomes during and following these “risky states” and will use them to inform the development of new holistic mitigation strategies Objective • Acquired and reviewed 2 years of retrospective data • Analyzed retrospective data and develop model • Designed application to display real time information to ICU staff about risky level Team • • • • • • • • • • • • • • • • Dustin Boone Tricia Bourie Christina Cain Michael Cocchi Jane Foley Agnes Hu (MIT) Retsef Levi (MIT) Lisa Lucia (Aptima, Inc.) Yiyin Ma (MIT) Ariel Mueller Sharon O’Donoghue Kristin O’Reilly Jeremy Richards Adam Traina (MIT) Donna Williams Kathryn Zieja • Nurse Consultants – Juliann Corey – Lynn Mackinson – Veronica Kelly PI’s • Danny Talmor • Ken Sands “ICU Intensity Index” Dashboard Methods 1. Identified drivers through retrospective review of root cause analyses 2. Identified harms (voluntary reports, billing data, IHI ICU global triggers tool 3. Analyzed 2 years of retrospective data for all ICU patients 2012 – 2014 “ Total Burden of Harm” Environment Predictors - Drivers Acuity SOFA Score TISS-28 Unplanned Procedures Length of Unit Stay Length of Hospital Stay Pts in first 24 hrs Experience Float Nurse New Nurse <1 year Traveling Nurse Rare Unit Procedure Inexperience with Procedure Care Team Boarding Patient Utilization Hours of Care Bed Utilization Resource Nurse Assignments Admissions Discharges Other Events Readmission "ED Critical" Admission with no Past History Admission from outside Hospital Night vs Day Weekend vs Weekday Special Event National Conference Preventable Harms CLABSI VAC/IVAC/PossVAP/ProbVAP High Tidal Volume VTE-PE ICU-Acquired Delirium Decrease in Function Mobility * Falls Medication Events CAUTI Potentially Preventable Harms ICU-Acquired Pressure Ulcer PTT > 100 while on Heparin INR > 6 while on Warfarin Hypoglycemina while on Heparin Infusion Oversedation Oversedation requiring Naloxone Iatrogenic Pneumothorax Reintubation./Unplanned extubation Readmission to ICU Positive C. Diff and Blood Culture Potential Harms Bleeding Lab Specimen Errors Identification Errors Reintubation and Unplanned Extubation Administering Naloxone Administering Vitamin K BUN or Creatinine Doubled Baseline … Results Conclusions • It was impossible to create a working list of MD’s and RN’s assigned to care for each ICU patient at any point in time from existing electronic data sources •It will be important to capture “drivers” that we have not considered in the first analysis of retrospective data Collaborators Funded by the generosity of the Gordon and Betty Moore Foundation Environment Predictors - Drivers Acuity SOFA Score TISS-28 Unplanned Procedures Length of Unit Stay Length of Hospital Stay Pts in first 24 hrs Experience Float Nurse New Nurse <1 year Traveling Nurse Rare Unit Procedure Inexperience with Procedure Care Team Boarding Patient Utilization Hours of Care Bed Utilization Resource Nurse Assignments Admissions Discharges Other Events Readmission "ED Critical" Admission with no Past History Admission from outside Hospital Night vs Day Weekend vs Weekday Special Event National Conference “ Total Burden of Harm” Preventable Harms CLABSI VAC/IVAC/PossVAP/ProbVAP High Tidal Volume VTE-PE ICU-Acquired Delirium Decrease in Function Mobility * Falls Medication Events CAUTI Potentially Preventable Harms ICU-Acquired Pressure Ulcer PTT > 100 while on Heparin INR > 6 while on Warfarin Hypoglycemina while on Heparin Infusion Oversedation Oversedation requiring Naloxone Iatrogenic Pneumothorax Reintubation./Unplanned extubation Readmission to ICU Positive C. Diff and Blood Culture Potential Harms Bleeding Lab Specimen Errors Identification Errors Reintubation and Unplanned Extubation Administering Naloxone Administering Vitamin K BUN or Creatinine Doubled Baseline … Moderate Risk State High Risk State Add a Patient Concern Add a Unit Concern