Division of Pediatric Otolaryngology - Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.
Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.
Laryngoscope. 2021 Jan;131 Suppl 1:S1-S10. doi: 10.1002/lary.28760. Epub 2020 May 21.
Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals.
Quality improvement initiative.
Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU.
In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability.
Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity.
N/A Laryngoscope, 131:S1-S10, 2021.
接受气道手术的儿科患者需要广泛的术后气道支持，这在术前可能难以预测。对术后资源需求的预测不准确会导致低效的护理，表现为意外的重症监护病房（ICU）入院、ICU 床位需求取消和 ICU 资源过度利用。在我们医院，儿科重症监护病房（PICU）资源利用效率低下，影响了安全性、可及性、吞吐量和财务状况。我们假设，医院 ICU 利用效率低下的主要驱动因素是手术安排错误以及对中危患者的不可预测性，并且可以使用改进方法在迭代周期中提高护理效率。通过测试这一假设，我们旨在为其他医院的类似工作提供一个框架。
质量改进倡议。
采用计划-执行-研究-行动（PDSA）方法，对一家学术性儿科医院进行了两轮改善护理水平效率的改革。在 PDSA 循环 1 中，我们旨在通过限制手术医嘱放置、创建需要入住 PICU 的手术标准清单和在电子病历手术医嘱中设置术后位置的硬停止来解决手术安排错误的问题。在 PDSA 循环 2 中，设计并实施了一种新的护理模式，称为“灰色地带”模式，其中中度气道受损风险的患者在麻醉后护理病房观察 2-5 小时。在此观察期结束后，患者将根据当前状况转移到所需的护理级别。在 PDSA 循环 1 中评估的措施是意外 ICU 入院和 ICU 床位请求取消。除了继续分析这些措施外，PDSA 循环 2 的评估措施还包括避免使用 ICU 床位、安全事件以及从延长观察期到 ICU 的二次转科。
在 PDSA 循环 1 中，没有观察到 ICU 意外入院人数的显著减少；然而，平均每月 ICU 床位取消率从 36.1%增加到 45.6%。在 PDSA 循环 2 中，平均每月意外 ICU 入院和取消的 ICU 床位请求分别从 1.3%降至 0.42%和从 45.6%降至 33.8%。在“灰色地带”中观察的患者中，229/245（93.5%）被转至延长观察，避免了 ICU 收治。财务分析显示，在研究期间，向支付方收取的费用有 110 万美元的差额，如果因增加的 PICU 床位可用性而接受更多的医院转科，医院有 51720 美元的收费差额机会。
通过减少意外 ICU 入院和 ICU 床位取消，同时避免对中度风险患者过度使用 ICU 资源，实施“灰色地带”护理模式提高了 ICU 资源利用效率。这在不影响患者护理安全的情况下实现，在按服务收费和基于价值的报销模式下都是合理的。虽然这种模式可能不适用于所有医疗环境，但它可以提高其他高手术量和高风险儿科医院的效率。
无。喉镜，131：S1-S10，2021 年。
