Hello, this is Joshua Meadow from the University of Wisconsin along with Christopher Zacco from Penn State University presenting a talk on providing value in neurocritical care. This is done in concert with the American Association of Neurologic Surgeons. The expenditures in the United States on healthcare are really quite astronomical. The costs are rising, it's becoming a larger and larger part of our gross domestic product and it's important for us to control costs as a key tenet for economic stability. When we think about providing value in the care that we provide to patients, we can almost look at it as an analogy of what value is when you buy a new technology. That is to say, if you were to go out and buy a high-definition television today, it might cost you $800 and the quality would be really quite substantial. If you were to have bought that same television with perhaps less quality of video five years ago, it might have cost you a few thousand dollars. So the idea in providing value is to do a better job of providing a product or a service and doing it at a lesser cost. We all know that as physicians, we try to provide the best possible care to our patients that we can. As neurosurgeons, many of us work very hard on the surgical side of things to be doing a more than technically adept job at the surgeries we perform. And oftentimes, we rely on our training to perform critical care treatment of our patients as well, and we may also rely on others' help in critical care units to help manage our patients. The focus of this talk is going to be on the medical side of things rather than on the surgical side of things. And what are the things that we can improve upon? Well, we can improve upon a number of different things in the medical side or medical treatment of patients. It is all one treatment of a patient. I agree, it's not medical versus surgical. But there are little things that we oftentimes overlook. Things like how we place a central line, how we place a ventriculostomy, how we manage our patients who could develop ventilator-associated events or pneumonias. How do we prevent from using expensive drugs when we don't need to? What can we do to improve the length of stays of our patients so that we can free up more hospital beds for other patients that come in because they have substantial medical needs? These are things that are very important to us in the neurocritical care realm. And these were things that we started to undertake in the Neurocritical Care Unit at the University of Wisconsin. There are many other quality improvement initiatives as well that we are undertaking and that you may undertake at your organization or institution to help provide better care for our patients and to do so in an efficient and effective manner. One thing that is very important to us is the multidisciplinary team. And in this picture, I show the ICU physician as being in the center with nursing and pharmacy and nutrition support and respiratory therapy and all these different services around them. The reality is that I thought most people would go insane if they actually looked at a diagram that shows how everybody points to everybody. It was just easier to draw the physician in the center. Realistically, the physician is really not the centerpiece of the team. The team is truly the team and everybody contributes their part to the team. This does not follow the joke of how many neurosurgeons does it take to screw in a light bulb with the answer being one and the world revolves around him. This is something that is different. This is an approach where everybody has their stakehold in what they do best and trying to find ways to integrate all those things that we do best together so that the outcome for the patient is optimized. When we built our program in neurocritical care in 2008, we set goals. The goals were to build a multidisciplinary team where there was interdisciplinary education. What that means is that you would find that there are times the nurses are actually educating the docs or the pharmacists are educating the docs and the nurses or the respiratory therapists are educating the nurses and the docs or vice versa. It wasn't always the doc that was responsible for educating the other staff. This allowed everybody to feel that they were needed and necessary and that they had something different to offer. It also allowed physicians to realize that the orders that they put in regarding the care and treatment of the patients did have substantial consequences and to learn better what those consequences were so that we could optimize efficiency and quality care. The focus on building a multidisciplinary team was to try to improve our outcomes and that's what we do through QI Projects. It was to try to decrease our costs. It was to try to improve patient satisfaction. It was also to try to improve employee satisfaction. This was before there were these HCAP things which have been popping up substantially and that you have probably become very aware of over the last year, year and a half. This is the team. This is our team of docs and nurses and respiratory therapists and pharmacists and dietitians that run our unit. We are quite a motley crew at the University of Wisconsin. We have daily multidisciplinary rounds with cross-disciplinary meetings. Again, it's that interdisciplinary approach of having different groups talk about the issues at hand and their impact on the patients. It involves all the specialties where we card flip and talk about every patient in the ICU, the Neurocritical Care Unit, that is to say, including patients that may board up in the Neurocritical Care Unit that are not patients that are of the Neurosurgery Service or Neurology Service. We do an introduction and exam performed as a team and we examine those patients in particular where there are certain questions or status changes that we do that as a team. We discuss the plan outside the patient room, typically with the family. If the patient is awake and able to participate, we discuss it inside the patient room, but we do try to respect as much quiet time as we can for the patients. We use an organ systems approach and that is so that we don't just focus on what's going on with the patient's brain, what's the intracranial pressure, if the patient's paralyzed or not because of an anatomic lesion, what's changing with the patient's status there. We want to be able to cover absolutely every organ system. We want to know what the blood pressure is and what the cardiac function is and what the pulmonary function is and how are we doing with fluids and electrolytes and et cetera. We break it down into these different subcategories so that we can optimize the care of the patient and the disposition is important for our nurse case management and social work services so that we can help move the patients on to their next chapter in recovery. To help promote interdisciplinary education, we have a daily journal club where we do one article for 30 minutes over lunch. They involve best practices. We identify our areas of weaknesses. We apply the best practices. We reassess and we invent original research when relevant. The articles could be nursing articles. They could be physician related articles. They could be pharmacy. They can be anything and it's presented by the respective group and people just bring their SAC lunch or whatever and discuss it over there. They don't have to have even read the article in advance, but if there are things that are valuable in the article, we then try to see what we can use those articles for because we know that there are many ways, little things that we could do to improve the outcomes of our patients. One of the major issues that we identified was nutrition and that is because the initiation of nutrition within the first five days after traumatic brain injury was found to be an independent factor affecting mortality. It was of great significance. There's only a few other measures that have actually proven to directly affect outcome, including hypoxia, intracranial hypertension, and arterial hypotension. To our surprise, nutrition really was not something that we thought of that was an independent predictor of outcome. When we looked at our nutritional inadequacy in 2008, we found that we were well below the nutritional needs of our patients. Patients were getting fed 61% of the calories that they needed while in the ICU and it would take five days to start feeds on average, where the goal was two days and the time to reach target rate was eight days. I think about not eating for five days, I think about not eating for four or five hours and I might be starting to get hungry and not feeling so good. It's important to recognize that it was not good practice to not feed our patients for five days. When we looked at the reasons why, only 1% of the time was it because our patients actually had GI intolerance. The vast majority of things that got in the way of them being fed were we couldn't get their starter regimen going, they were NPO for procedures that may or may not happen that day, maybe they happen the next day and so they kept getting NPO'd for no good reason, we forgot to document it, it was a big oops or we missed. These were things that were not really acceptable. What we did was we developed a protocol in which all of our patients got post-pyloric dopoff tubes. If they didn't have facial fractures, they were done at the bedside with a CoreTrack device using specially trained nurses or myself as a neurointensivist. If they did have facial fractures, they were placed under radiographic guidance in the fluoroscopy suite down in radiology. By doing this, we were able to increase the percent of prescribed calories for the neuro ICU up to 85% in 2010 and as of recent, we've exceeded 91% in the neurocritical care unit. Within the first year, we went from 60% feeds to over 80% feeds, which is better than the goal from aspirin of 65%. Part of the way we did this is that they were not allowed to be, the patients were not allowed to be NPO'd after midnight if they had a post-pyloric feeding tube. This did require some convincing of our anesthesia colleagues, but because the literature was there to support it and it's constantly done for patients with serious burns, they went along with it and we did not have an aspiration event as a consequence, at least as far as we could tell an aspiration event as a consequence of the post-pyloric feeds. We also made sure that our tube feeds were getting initiated much faster. It was originally five days, it was 39 hours in the first year and it's about 22 hours now currently in the neuro ICU. The goal rate was achieved by 66 hours instead of 72 hours, which is great considering that the goal feed rate before was eight days. Currently now, we're sitting more at 48 to 50 hours for our goal rate being achieved in the neurocritical care unit. We also wanted to use indirect calorimetry as a means by which to identify patients that were not being fed an appropriate amount of food. We know that underfeeding can lead to impaired wound healing, organ function, and immunologic status, and we know that overfeeding is bad because it can lead to hyperglycemia, electrolyte abnormalities, hepatic problems, etc. What we were able to do at first was to look at our patients that were either very thin patients or morbidly obese patients because those were the patients that were the hardest to determine using formulas as to what their caloric needs were. As it turns out, when we looked at those patients and we used indirect calorimetry to measure their caloric needs, we found that our dietician was underestimating their needs by roughly 500 kcals. If you use the formulas that are typically used to identify caloric needs, we would have underestimated the caloric needs of our patients by over 750 kcals per day. So this was an interesting finding that's in the process of being published, and consequent to this, we use indirect calorimetry on our patients that are either morbidly obese or that are otherwise underweight given their height and age. DVT is a significant problem. It affects 30% of moderate and severe TBI patients and 18% of stroke patients. We consider it a completely preventable disease. Now, it may or may not be completely preventable, but one of the things that we do recognize is that we probably could do a better job of preventing it, and the reason why we ought to try to do a better job of preventing it is that in the event that a person did develop a significant DVT or pulmonary embolism, it might require full anticoagulation, and in the presence of a recent head injury, stroke, etc., the risk may be substantial enough that it could mitigate a poor outcome. And so if we can do something to prevent the clot in the first place, that ounce of prevention versus a pound of cure may be really the greatest understatement in the world when it comes to DVT and PE prevention. Our unit always used sequential compression devices and thromboembolic deterrent stockings, but chemoprophylaxis, meaning the use of either low molecular weight heparin or subcutaneous unfractionated heparin, was not something that was routinely used in our unit. We wanted to see if we could form or have a significant reduction in DVT formation, and we noticed that the use of blood thinners that had been written about in the literature before craniotomies or craniectomies increased the hemorrhage risk by 10%, and this really isn't some surprising event when you think of giving an anticoagulant prior to a surgery. But the real question is, after the surgery, at what point is it safe to go ahead and give an anticoagulant in prophylaxis doses? So we've put together a protocol where patients greater than the age of 18 that were going to be in the ICU for more than 48 hours, that were not pregnant, did not have a coagulopathy, did not have continued bleeding from a GI bleed, et cetera, did not have a history of heparin-induced thrombocytopenia, would be included in the protocol. What I will say is that some of the faculty, and I'll say that this affected roughly 30% of the patients, did not participate in the protocol because they were dead set against use of anticoagulation in prophylaxis doses after a traumatic brain injury. Those patients were automatically excluded, but the other 70% of the patients were not, and there was no exclusion based on the type of hemorrhage or type of injury. We followed a protocol in that the CT scan was obtained per the faculty's individual scanning practices, and that the patient would have an initial scan, which they always had coming into our neurocritical care unit, and oftentimes they would have a follow-up scan at some point. As long as that follow-up scan was at least three hours after the presenting scan, and there was no change in those two scans, 24 hours after the no-change head CT, we would then begin subcutaneous unfractionated heparin or subcutaneous low molecular weight heparin. The subcutaneous unfractionated heparin was 5,000 units sub-Q BID, and if it was low molecular weight heparin, it was delta-parent 5,000 units sub-Q daily. All patients received the SCDs and TED-HOS before arriving in the unit. We did mine our data through our electronic medical record. If the patient ever had their chemoprophylaxis stop, we recorded it, and of course we were able to cross-reference this with the M&M reports, any reports of surgeries of any kind on the patients after starting the protocol, et cetera. What we found was that when we looked specifically at our trauma patients, we found that there was only one patient that had a questionable event that happened as a result of the use of low molecular weight heparin or sub-Q heparin, and that is to say there was no acute bleeding in any of the patients at all, but one of the patients that was a little bit older that had a subdural hematoma that was of size did develop a chronic subdural hematoma that needed to be drained a number of weeks later. Whether or not that sub-Q heparin that was given to that patient was the result in that patient's drainage of a chronic subdural hematoma is not completely known. We do feel the natural history probably was such that if they had not received any sub-Q heparin, they probably still would have needed to have that hematoma drained, but there was no acute bleeding identified in any of the patients that were on the protocol, and that was a very key issue. The results specific to TBI were published in Neurocritical Care in April of 2013, and we are currently working on the paper for the other patients in the ICU. Again, we did not exclude those patients that had contusions, subdural hematomas, whatever the issue was, as long as there was no bleeding identified between two scans that were at least three hours apart, 24 hours after that point, we started chemoprophylaxis. The idea is to try to optimize the prevention of DVTs. If we were to have had DVTs and PEs that were of substance in our patients, using full anticoagulation would likely have been a lot riskier than using the chemoprophylaxis. Infections are a significant issue. JACO considers central line infections in hospital, slash ventilator-acquired pneumonias or ventilator-acquired events, a series of preventable complications, which were terrible with respect to ventilator-associated pneumonias. The neuroICU at the University of Wisconsin originally had three times the national average of ventilator-associated pneumonias as compared to the National Healthcare Safety Network data. We focused hard on our quality improvement initiatives. We increased our head-to-bed to greater than 30. We did our toothbrushing and mouthwashing every two hours. We used chlorhexidine mouthwash every 12 hours. We performed early trachs when needed. We made sure that we weren't doing sputum samples with quantitative BALs that were either blind or directed with a bronchoscope, and the reason why we did that was because it's very easy to have organisms growing on a sputum sample, but the real question is, are there enough organisms quantitatively that the body could not fight them? And so the most virulent organisms typically need 10 to the third organisms on the culture to be able to be considered untreatable by the body's immune system alone, and so as a consequence of this, that's what we used. Some organisms, maybe 10 to the sixth, is necessary before the body can't clear them. Needless to say, we would use our quantitative cultures to help. As a result of this, over the first eight months, we had zero VAPs, which was really pretty substantial. It was not statistically significant at eight months. We believe that with our current reporting, now that we went to 16 months with a single VAP, that it is statistically significant, and we are in the process of submitting a manuscript on this. If you look at this graph, you'll see that we started off with the blue line, that's us in the Neurocritical Care Unit, and we were, again, we were triple the national average. If you look at the purple line, that would be the National Healthcare Safety Network, and so we were doing very poorly. The orange line was the University of Wisconsin's overall ventilator-associated pneumonia days or infections per 1,000 vent days. After adopting all of these practices and some additional ones, which included changing the suction canisters and the inline suctions every day along with their tubing because they were getting to be quite, we found that our VAP rates dropped out substantially and the rest of the hospital started following what the Neurocritical Care Unit was doing and they too started to fall well below the National Healthcare Safety Network risk of developing Ventilator Associated Pneumonias. Extraventricular drains are a significant risk for infection in some units. The National Healthcare Safety Network had report, I'm sorry, the National Average for EVD infections was six to 9%, the UW had a 0% infection rate over 12 months with two proven contaminant specimens that actually were contaminated in the lab, not in the ICU. The way we were able to accomplish this was very straightforward. We tunneled all of our catheters, there was a predetermined distance that they needed to be tunneled. All of the patients did have to get a very solid, thorough prep before the ventriculostomy was placed. Everybody wore sterile gowns and used sterile precautions for everything, including the prepping of the Buretrol and the transducer. And then the drains were sampled only by a single physician to obtain the cultures that would be sent down to the lab. By limiting the amount of access to the system, we were able to help prevent infection as well as by protocolizing the manner in which the system was accessed and the devices were placed. This is no difference than what was done with This is no difference than what was done with patients that had central lines placed. Again, we look at the great work done by Peter Pronovost in preventing central line infections using his checklist and following along with work that he had already done. We made sure that everybody had a sterile place line in the neuro ICU. Everybody wore sterile, used sterile precautions. Patients were prepped with a solid prep and they were draped accordingly. And the need, if the need arose for an emergency to place a central line, then that central line that was emergently placed, which may or may not have been placed under the sterile conditions that we would like, was immediately replaced within 24 hours after that emergency line was placed. This prevented potentially contaminated lines from being left in the patient for any length of time. As a consequence of that, the surgeon placed lines in the neuro ICU were never infected over the course of the year. And one PICC line, as it turns out, did become infected. In addition to the placement procedures and protocols, the accessing procedure and protocols were also very important. And we were very meticulous with how they were accessed. And our nurses specifically did a great job in preventing the spread of infection by making sure that the lines were appropriately dressed and appropriately prepped anytime they were accessed. In standpoint, the biggest conclusion is if you follow best practices, you can improve infection rates. Now for medication costs, it's very interesting in that we typically like to use those things that we are used to using, and it's no different, be it a surgical technology or a medication that we like to run in the ICU. But the real question is how effective are the meds that we're using and how efficient and cost-effective are these meds that we're using? Because that's something that's really very problematic. And oftentimes, I don't think as neurosurgeons, we necessarily take into consideration these different factors. One of the things that we did was we created a list of the top 15 drug costs collectively in the ICU over the course of a year. And we found nicardopine was at the top of the list. And it's funny because when I then wanted to look and see who were the most expensive physicians in the Neurocritical Care Unit, I found that I was the third most expensive physician in the Neurocritical Care Unit out of 15 physicians that are out of 15 neurosurgeons that had patients up there. And I think the first thing is just to clean your own house before you start talking to your partners about what you can do to reduce costs. But once I was able to reduce the expense of some of our medications, it became obvious that we could reduce costs in a pretty substantial manner. And this is the picture of myself being a very expensive physician and trying to think of ways that we could reduce our costs. And so we started looking since nicardopine was one of the ones at the top, it seemed like low hanging fruit because there are other blood pressure lowering agents that we could be using. One of the things that was substantial was that nicardopine was costing us $1,500 per patient per day on average. Yet if they had normal kidneys and normal livers, we found that we could use nitroprusside with the thiosulfate antidote for roughly $50 per patient per day. Now, some people say, well, they're concerned you could really just drop blood pressure too low in patients when you use nitroprusside. If you have a good protocol, that won't happen. And not more so than nicardopine because frankly, nitroprusside was fair than nicardopine to changes that you make in the infusion rate. The other thing that is interesting is that we found that there are many times that nicardopine couldn't control blood pressure where nitroprusside could. Very rarely did we ever see the opposite. So it was a natural switch for us to go to nitroprusside and thiosulfate. Again, for those patients that had normal liver or kidney function, if not, we would still consider using nicardopine. Esmolol was very expensive. It was costing us almost $80,000 a year at $1,200 per patient per day. It's great for controlling rate. It's got a very fast onset and a very fast release. However, if you're really trying to control blood pressure and heart rate at the same time, you might consider lobetalol, which has the alpha activity as well as the beta activity that Esmolol has. It's true that it doesn't respond as quickly, but then again, if you don't need that quick of a response when shutting off the med, it works very well. It does respond very quickly when given to bring down IV, to bring down blood pressure from an intravenous infusion. So its response time to working is great. It just does last a bit longer than, or a significant bit longer than Esmolol would when you shut the drip off. The difference in price though for a lobetalol infusion versus an Esmolol infusion was substantial. Again, the infusion per patient per day was roughly $1,200 for Esmolol. For lobetalol, it was roughly $3. What we found when we first started studying this, the Keppra usage in our unit, and it's debatable whether or not we should be using Keppra as a first line prevention for seizures or whatever, but what we will note is that in our unit, it's very commonplace to use Keppra as a first line prevention of seizures or treatment for seizures. And at the time that we did our analysis, oral Keppra had become off patent, whereas the IV version had not. And the IV version was at that point, 200 times more money than the oral version, which was really substantial. So as a consequence of that, we tried to switch everybody to oral Keppra and we were able to do so because we had post-pyloric DOP off tubes in the vast majority of our patients. And as a consequence of having these DOP off tubes in place for feeding, because of our nutrition QI, we're able to use them for giving medications accordingly. Albumin is something else that was used in our neuro ICU substantially for patients with subarachnoid hemorrhage. And we did our best to try to limit the use of albumin because we found that the vast majority of our patients seem to be benefiting more from the hypertonic sodium solution than from the albumin itself. In addition to that, the albumin is a blood product and it is a pooled blood product for many donors. We think that we are checking for all the various diseases that we can think of, be it HIV, the different hepatitis, et cetera. But we still don't know about the different diseases that could be out there that we just don't know about yet. And giving somebody a transfusion of a human blood product that is from a pool of multiple people does not necessarily preclude the next disease process from being transmitted via a blood transfusion, such as by giving albumin. In addition to trying to cut costs for the medications we listed above and the human blood product we talked about with albumin, we also found that cysatricurium or paralytic drips were very expensive. And again, if you have normal liver and kidney function, you may not need to use cysatricurium, you might be able to use vecuronium instead, which is roughly a six-fold decrease in cost. So you notice that our costs for albumin, I'm sorry, for nicartopine were roughly $164,000. By doing this QI project, we were able to drop that down to roughly $31,000 overall for the year. Part of the costs that were there, that made up that $31,000 were because of patients that did have liver or renal dysfunction. And part of it is because our colleagues in the anesthesia world typically use nicartopine in the operating room for patients. And as a consequence of that, there were charges to the neurocritical care unit while we were in the process of transitioning the patient from nicartopine that was given in the operating room to nitroprusside given in the neurosurgical ICU or neurosciences ICU. There is one other thing too, some people have stated in the past that they thought that nitroprusside would result in elevated intracranial pressure as opposed to nicartopine because of venodilatation. I'd like to put to rest that physiology and physics does not make any sense. The vessels do not push open. The central venous pressure at best is six millimeters of mercury. So if the pressure in the head is greater than six millimeters of mercury, there is no reason to force additional blood into the head to raise intracranial pressure by using something that could work on the venous side, such as nitroprusside. If anything, the reason why nitroprusside could raise intracranial pressure more than nicartopine is because of the arterial dilatation that happens that is more profound with nitroprusside than with nicartopine. There is an Esmolol trend as well that we were showing as a consequence of dropping down our Esmolol, we saved $47,000 by using labetalol infusions. Keppra, that saved us roughly $15,000. Albumin, by dropping it off substantially, we saved about 25,000 a year. And by switching to becqueronium from cysatricurium, the vast majority of the time, we were able to save roughly $22,000 in the use of paralytic meds. If you look at our fiscal year 2008-2009, you'll find that our nicartopine, which was at the top, and all the other yellow drugs that were at the top were switched substantially. And now, if you looked at our most expensive drugs by acquisition cost in fiscal year 2009-2010, you'd find that our Factor VII was the most expensive, and that was just because there was no other, at that time, no other option for reversal of coagulopathy besides FFP and vitamin K, which we would give anyways to those patients that were on Coumadin. Now, with the advent of other drugs and other preparations, including PCC, our use of activated Factor VII has dropped off as well. And we are very much in control of which patients are actually going to get activated Factor VII in our unit. And this could be a separate talk for reversal strategies in patients with coagulopathies. The overall was a 30.4% reduction in cost over two years, and in actual cost savings, that is what we pay for the drugs, of $278,000. If we limit the use of cost of designer medications, we can still achieve quality outcomes if we do so in a protocolized manner that optimizes patient safety first, and at the same time, keeps our costs in check so we have that money for other things in the Neurocritical Care Unit. Wisconsin length of stay is a significant problem. It may differ in your state, but in the state of Wisconsin, one of the problems that we have is the advanced directive issue. And that if there is no advanced directive issue, I'm sorry, if there is no advanced directive on file for the patient, why then the patient's family has to proceed with guardianship, or the state has to proceed with obtaining a guardian for the patient in order for the patient to be moved to the next level of care. Now within the hospital system, that is not a problem, but if the patient should need a nursing facility, a long-term acute care hospital, a rehab institution outside of the university system, then the patient could not be transferred without having that advanced directive done or guardianship obtained. So one of the things that we did that we thought was very important was we would have our social workers introduce themselves, or our nurse case managers introduce themselves within 24 hours of the patient having an injury. We just figured that was just good communication. And at that time, within 48 hours, we would assess if the patient had a healthcare power of attorney. And if they didn't have one, we would obtain it immediately if they were awake and able to do it, i.e. a patient who has a subarachnoid hemorrhage, but is otherwise completely oriented. For patients that may potentially need guardianship, meaning those patients that are not oriented or able to participate in the decision-making, we began giving the families the application within 72 hours, and we had them just consider the application, but not fill it out until seven days into the treatment of the patient, at which point, if we were going to continue aggressive medical management and the patient was unable to make their own decisions by that point, we would either have them hire their own attorney, or if they could not afford one, the hospital attorney would be used to obtain the appropriate paperwork to proceed with guardianship. And this allowed us to facilitate discharges to LTACs, nursing homes, et cetera. We did have a population from August of 2007 to 2009 with patient length of stay being our goal. We enacted the protocol in 2008. And so if you look at the comparison group, in 07-08, there were 1,604 discharges. In 08-09, there were 1,901 discharges. We looked at the control patients and we found that the control patients really actually had 18 days fewer than expected or predicted, which was great. But if you compared that to what we did after the protocol, they had 278 days fewer than expected or predicted, which was phenomenal. This meant a mean ICU length of stay decrease of about 0.77 days. And when you take into consideration that days are dollars, and we're not talking about patient charges, right? Because those are fictitious numbers. And when I say fictitious, they vary so substantially between whichever insurance is paying, or if there is no insurance. We didn't want to go with indirect costs because there's no way to account for those specifically to each individual patient and be accurate. We wanted to look at specifically our direct hospital costs. And the bottom line in saving those 0.77 days from the ICU was $2.66 million in costs saved to the Neurocritical Care Unit and to our hospital. So basically a protocol just facilitates simple communication with families really made a huge difference and really made us very successful in getting our patients' needs met sooner and dropping our length of stay. So the overall picture is really pretty substantial when you look at everything that we've talked about today. In addition to all the meds that we'd save money on and the decrease in patient length of stay and decreasing the infection substantially and decreasing the risks of DVT and the like, we found that our patients were very happy with us or our patients' families were very happy with us. The national average on the Press Guinea survey is 89%. The Neuro ICU was 94.6%. The hospital's patient satisfaction was 91%. So our hospital does well but our Neuro ICU was really exceptional. And a small percent change is really a pretty substantial difference when you're working at that high at the end of the curve. We also found that our employees were very satisfied. Many of them believing that the teamwork was very good but 95% believing that the quality of care was excellent. And this has changed substantially since we invoked this team approach. And it is an enjoyable environment. And here's an example where I fell asleep accidentally in the middle of the night in a chair in the Neuro ICU and Joe, our respiratory therapist, caught me snoring. And so to try to mitigate my obstructive sleep apnea, he flipped the switch and I jumped out of my chair when the system pressurized. So we do have fun together. We enjoy each other's company. We work hard together. And as a team, we've gotten great results together for our patients. And if you look at our first year's mortality statistics, the mortality in the Neuro ICU compared to the national averages was 44% below the national average. We went from being about the national average to being substantially better than the national average for the sickest patients, those that were ventilated for more than 96 hours. For those that were ventilated less than 96 hours, there was a 12% reduction in mortality over the national average. And for non-intubated patients, there was a 27% reduction in mortality over non-intubated patients. So our mortality outcomes were fantastic. Anecdotally, our patient outcomes overall were fantastic. We saved a lot of money in doing so because we thought this was very important. I will note that the infection cost reduction is a number of contention in my mind. And that is to say, I find it hard to believe that a urinary tract infection can cost somewhere between 20 and $30,000. But if you keep in mind all these different infection issues and the prevention of central line infections, ventilator-associated pneumonias, and you use the numbers that were provided to us, this reduction is pretty significant. So in conclusion, with costs skyrocketing and a need to care for our patients that are critically ill, we must really, really look closely at the number of things that we can do to try to improve their outcomes and to do so in a manner that improves their overall health. And we feel that by reducing complications, simple medical complications, by making sure that our patients get the nutritional needs met, that they do have prevention of infection in an appropriate manner, that we do all these different things, we feel that these quality improvement initiatives that we've taken on will improve the value of care that we deliver. We have other quality improvement initiatives that we are currently working on. I'm sure there are other quality initiatives that you are working on at your institution. And we hope that this little taste of what we've done in neurocritical care at the University of Wisconsin is helpful to you and your practice. Again, this was really quite a team effort. This is some acknowledgements of people that were involved with the various quality improvement initiatives. There are many other names that are not on here that provide just excellent care to our patients and are very strong patient advocates and have done great work as part of our neurocritical care team. With an important quote, excellence is the result of caring more than others think is wise, risking more than others think is safe, dreaming more than others think is practical and expecting more than others think is possible. Thank you very much for your time today.

neurocritical care

healthcare costs

value in healthcare

quality improvement initiatives

patient outcomes

employee satisfaction

medical side of care

interdisciplinary teamwork