Exploring Drivers of Mortality Using the 2x2 Analysis First Quadrant: Focusing on the Palliative Car

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Exploring Drivers of Mortality Using the 2x2
AnalysisFirst Quadrant Focusing on the
Palliative Care Population May 8, 2008

• Hackensack University Medical Center
• Baptist Memorial Hospital-Memphis
• Baptist Memorial Hospital Union City

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Baseline Mortality ResultsforPresenting
Hospitals
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Mortality Two-Year Trend7/06 to 6/07
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Use of Palliative Care CodeJuly 2006 to June 2007
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Hackensack University Medical Center

• Mary Panico, Director of Clinical Knowledge
  Management and Reporting

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Approach to Reducing MortalityHackensack
University Medical Center

• Mary Panico, RN,BSN,MBA
• Director of Clinical Knowledge Management and
  Public Reporting

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Hackensack University Medical Center
HUMC, a 781 bed teaching and research hospital
affiliated with the University of Medicine and
Dentistry of New Jersey - New Jersey Medical
School, is the largest provider of inpatient and
outpatient services in the state of New Jersey
with a 97 daily census.
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Mortality Views

• Retrospective Review
• Trigger Tool
• IHI 2x2
• Peer Review
• Public Reporting
• Administrative Data
• Documentation/coding alignment
• Multiple Risk Adjustment Methodologies
• National Databases
• NISQIP
• STS
• ACC

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Aims and Goals

• Goal
• Decrease unadjusted mortality by 25
• Aims
• Decrease Failure to Rescue
• Increase Identification of Communication
  Planning Failures
• Decrease Code Rate
• Develop Pain Palliative Care Initiative
• Decrease VAP rates in the ICU
• Decrease Line sepsis in the ICU

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2X2
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Initial focus

• 100 Mortality Review
• Analyze Failure to Rescue
• Refine MDR rounds outside ICU
• Include Advance Directives
• Include Key Project Indicators
• Address Medication Reconciliation
• Implemented ICU collaborative
• Sepsis bundle
• VAP bundle
• Central Line bundle
• Evaluate glycemic control in the ICU

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Progress Implemented

• Develop Pain and Palliative Care model
• 14 Hospice Beds
• Deploy Rapid Response Team
• Implement improved communication tool SBAR
• Early Sepsis identification and intervention
• Refine MDR rounds outside ICU to include
• Advance Directives, Daily plan of care
• Key Project Indicators
• Perfect Admit Perfect discharge
• Medication Reconciliation
• Spread the ICU collaborative (CCU, SICU)
• VAP bundle
• Central Line bundle
• Include Glycemic control and Sepsis bundle
• Quantify the cost of resuscitation and impact on
  ICU utilization

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Approach
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HSMR JARMAN
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QUEST
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APR DRG
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Interpretation of Results

• Observed to Expected (O/E) ratios
• Represents our hospitals outcomes in comparison
  to the other 143 ACS-NSQIP hospitals, adjusting
  for hospital-to-hospital differences in patient
  characteristics, comorbidities, and preoperative
  laboratory values.

2.50
2.00
1.50
1.00
0.50
HUMC
1.00
ACS-NSQIP Hospital ID Number
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Baptist Memorial Hospital-MemphisMortality
Drivers

• Mary Ann Northern, PI Specialist

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Quest Mortality Data
Note Bapt Mem
Memphis results were presented by Dr. Paul
Batalden at European IHI conference 4/21/08
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Key Mortality Drivers(IHI ICU Collaborative FY
2002 FY 2007)

• 40 reduction in ICU LOS
• 39 reduction in ICU mortality
• 41 decrease in vent length of stay
• Decrease in VAPS- 23 reduction in VAP rate (3.34
  vs 2.57). 
• Decrease in Central Line Associated Blood Stream
  Infections-33 drop in BSI rate (from 5.57 in
  2003 to 2.46 in 2007).  
• Sepsis mortality rate 53 reduction (was 40 in
  2004 for all patients coded in severe
  sepsis/septic shock with at least one ICU day. In
  2007 mortality was reduced to 19) 
• Door-to-Balloon Time decreased by 37 (from 110
  minutes in 2006 to 70 minutes 2008)

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IHI ICU Sepsis Bundle
Mortality decreased from 41 in 2005 to 19 in
2008
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IHI ED
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Key Mortality Drivers(End-of-Life Care)

• 2006 Leased 6 beds to home healthcare for
  general inpatient hospice services
• 2007 Increased palliative care staffing to two
  RNs and a MD Medical Director
• 2007 - Educated palliative care nurses on Canopy
  case management software to aid case finding.
  Palliative care nurses document patients wishes
  in absence of Living Will or Advanced Directive
• 2007 Adopted Futile Care Policy
• 2008 Palliative Care Services changing
  educational focus to Advanced Care Planning vs.
  end-of-life

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Defining the Target

• 2x2 Box analysis to identify where and what
  kind of codes were occurring outside the ICU
• Prioritize Mortality Review Unexpected, outside
  ICU
• Medical Response Team
• Condition H

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Baptist Memorial Hospital Union City

• Teresa Vinson, RHIT, Chief Quality Officer
• Roma King, RN, Case Management Coordinator

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Mortality Driver Diagram
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Mortality Team Meeting
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Mortality Team Meeting Notes
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Mortality Team Meeting Notes
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Mortality Team Meeting Notes
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Mortality Team Meeting Notes
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• QUESTIONS?

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KNOWLEDGE TRANSFER Mortality
Advice Package
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KNOWLEDGE TRANSFER Palliative Care
We need more Palliative Care/Hospice Content!!