Hello, my name is Rupa Kohlisath. I'm the Director of Critical Care Institute for Mount Sinai Health System. My topic today is patient flow. I have no disclosures to report. There are four main objectives we will be talking about in this session. To highlight the benefits of having a critical care organization to facilitate patient flow, to explore the role of interdisciplinary collaborations that ensure appropriate patient care, to share our real-world case studies that have optimized critical care flow in normal, strained, and crisis situations, and also to describe innovative technologies and best practices that can streamline the care delivery process. I'm going to begin by giving some background on Mount Sinai Health System and the Institute for Critical Care Medicine. Mount Sinai Health System is one of New York City's largest health systems. There are eight hospitals located throughout New York City and Long Island, and seven of those campuses have ICU beds. We see over 4.1 million patient visits per year and have more than 42,000 employees. We are an academic research center with numerous residencies, fellowships, and our own medical school, the Icahn School of Medicine. The Institute for Critical Care Medicine is a critical care organization. And what is a critical care organization? A CCO is defined by having a physician leader who has governance of majority of ICUs. The benefits of having a CCO span through clinical, operational, quality, education, and research areas. ICCM was initially created to standardize quality in the ICUs. However, over time, its role expanded to reduce wasteful practices, streamline our hospital throughput, unify our education, training, and research, and as we saw with COVID and recent nursing strike, scale up high-intensity staffing expeditiously during crisis. ICCM is currently made up of more than 100 intensivists across seven Mount Sinai campuses and is home to 19 ICUs and manages patients throughout the continuum of care with our many teams and programs that function inside and outside of the ICU. There are 27 critical care organizations in North America and we are one of the largest and one of the few with a female leader. Inclusive of our three fellowships, we are also one of the largest overall critical care training program in the country. Thank you. Having a critical care organization at Mount Sinai has laid the foundation for effectively managing capacity and patient flow processes, both inside and outside the ICUs. Some of the benefits of being a critical care organization that impact efficient patient flow are coordinated clinical processes and workflows across ICUs and specialties, a unified critical care staff who have training in a wide range of specialties, internal medicine, emergency medicine, anesthesiology, pulmonary, nephrology, cardiothoracic surgery, to name a few. A centralized critical care governance, communication system and escalation pathway rather than being siloed in individual departments. Shared resources across ICUs and campuses, established critical care teams and services that function throughout the entire campus and also throughout the health system. And hence, by all these processes, reduce waste and cost from redundancies of processes. To learn more about building critical care organizations and the value they bring, I encourage you to review the publications put forth by the Society of Critical Care Medicine's Academic Leaders in Critical Care Task Force, Members of this task force include, Drs. Oropallo, a senior intensivist within the Institute for Critical Care Medicine at Mount Sinai, and Dr. Steven Pastoris, who is the moderator of this course. I will first describe the tools we use to manage patient flow at our usual capacity. Managing flow of critical care patients is multifaceted and can occur within individual hospitals and across multiple sites of the health system. The graphic on the left outlines the teams, services, pathways we use to optimize admissions and discharges to the ICUs within individual hospitals. These teams and programs are rapid response team, step down support team, respiratory recovery pathway and vascular access service. The graphic on the right displays health system-wide programs we've implemented to coordinate care and level load patients across all seven of our hospital campuses with ICU beds to ensure all critically ill patients are receiving the appropriate level of care in a timely fashion. These services are central intensivist service, telehealth support for procedures, centralized triage for tunneled catheters. Health system-wide programs are implemented in collaboration with Mount Sinai Clinical Command Center. To support and steer a system approach for all of our hospital campuses, Mount Sinai has a Clinical Command Center. The mission of the Clinical Command Center is to deliver the right care to the right patient at the right time with the right resources every time. Comprised of a team of clinicians, they are accessible 24-7 as a single point of contact to coordinate throughput, bed management, transfer and telehealth logistics and EMS. They also ensure the health system works in unison in times of crisis and emergencies. In collaboration with the Clinical Command Center, the Institute for Critical Care Medicine launched the central intensivist service in May of 2022. The central intensivist serves as the first point of contact for all critical care transfer requests for Mount Sinai Health System sites, affiliates, as well as other hospitals seeking higher level of care for their patients. The central intensivist team ensures that patients are triaged to the appropriate level of care, whether they're treated in place, transferred to a specialized ICU or referred to a different specialty. The central intensivist is available 24-7. This service has effectively improved patient flow in individual ICUs in each hospital, as well as the hospital system overall. Once a physician requests critical care placement, the central intensivist is contacted to assess patient suitability for transfer to an ICU. If further consult with a specialty physician is required, the Clinical Command Center will connect the requesting physician, central intensivist, and subspecialist with the one single call. Usually this is a three-way communication that is set up immediately at the beginning of the call or within five minutes of request from the central intensivist. Some of the key indicators of success for the central intensivist service have been the reduction in turnaround time for transfer acceptance of our sickest patients. Given the nature of the ICU environment, most clinical cases are of high acuity and a quick turnaround time allows the placement of the right patient in the right bed at the right time, which potentially can lead to better patient outcomes, as well as an overall optimized system for utilizing ICU beds. Furthermore, it also allows for a reduction in turnaround time from transfer requests to bed occupied, increasing the cohesiveness of the health system to work together to meet patient needs and patient load. Since the central intensivist service went live in May of 2022, there have been 1,630 central intensivist assessments. This data shows that the time to clinical decision is 28 minutes, which is 53 minutes faster than the pre-central intensivist implementation after removing outliers. The service has led to a reduced transfer turnaround time by optimizing the use of shared resources and information across units and the hospital system as a whole, improving the quality of patient care overall. Another service that is central to managing patient flow is the rapid response team. This round the clock team was established in 2017 to respond to critical care consults for decompensating patients outside of the ICUs. Over time, the scope of the rapid response team expanded to responding to cardiac arrest on the floors. The rapid response team is a multidisciplinary team comprising of an intensivist, a clinical specialist, a critical care follow, a critical care APP, an RN, as well as a respiratory therapist. Data shows that in 2022, the rapid response team assessed 5,000 consults at Mount Sinai Hospital. To ensure the effectiveness of RRT or the rapid response team, we've established clear guidelines that outline the various patient conditions and clinical indicators for which frontline providers can request RRT consultations. These criteria cover a wide range of scenarios, including instances where there is a sudden decline in systolic blood pressure or unexplained changes in patient's mental status. It's important to stress that we also aim to empower staff at every level of the primary team, including nurses, to reach out to RRT even in situation where these specific criteria are not met. If there is a concern regarding the patient's overall condition or appearance. The rapid response team allows the intensivist to act as the central decision maker for ICU escalations and incorporates a centralized throughput process that leads to optimization of ICU beds and resources. It also allows for intensivist to intensivist communication, facilitating handoffs and effectively maintaining continuity of care. The rapid response team also provides a clear understanding of the nature of our patients we care for. It also allows for the opportunity to move palliative care upstream in patient's care plan or treat patients in their current unit. To review some of this data on this slide, in 2022, 56% of the patients remained on the unit and were treated on the floors by the rapid response team. And another 12% to the step-down units. Seven of these patients were moved to a palliative care unit. The step-down support service was created this year to enhance the care we provide to patients that may not be appropriate for an ICU, but are still at risk of decompensation, but have not decompensated yet. This team uses a preventative model that leverages artificial intelligence to identify step-down patients that are showing signs of potential decompensation. The algorithm evaluates all step-down patients within Mount Sinai Hospital and scores them based on lab results, vital sign, ECG interpretation, and structured clinical nursing documentation. There is then a feedback loop in which step-down support team can provide insight on whether the algorithm correctly identified a patient at risk for decompensation, and the model will continue to learn and adjust based on feedback. The step-down support team was honored this year with the Physician of the Year Team Award in partnership with NineVest, which is one of Mount Sinai Hospital's medicine step-down units. This team also has been recognized as one of the rare preventative care models used in an inpatient setting, as most occur in an outpatient setting or an ambulatory care setting. Next, we will discuss a pathway we use for ICU patients on mechanical ventilation. The Respiratory Recovery Pathway is a modified version of the Society for Critical Care Medicine's ICU Liberation Bundle, and it is now used in all ICUs across the health system. Respiratory Recovery Pathway is made up of orders and tasks that bedside clinicians and nurses carry out in order to liberate patients from the ventilator, ultimately decreasing ICU length of stay and risk for complications because patients are woken up, mobilized early and daily. If patients are unable to be liberated from the ventilator, they get a timely tracheostomy performed by our intensivists to help them wean or help them being placed in an outside facility, such as an LTAC. By liberating patients from mechanical ventilation or performing a timely tracheostomy, we are able to optimize our ICU bed utilization and downgrade patients who can continue their care on the floors or outside the hospital system. Intensivists from across our health system have undergone training in percutaneous tracheostomies so they can efficiently perform this procedure for their patients at the bedside, eliminating the need for a trip to the operating room or consulting other teams such as ENT or general surgery for this procedure. Once faculty have completed percutaneous tracheostomy training, their first few real-time tracheostomies are performed under in-person supervision of our senior intensivists. After a few in-person supervised procedures, faculty are then transitioned to being supervised through our telehealth devices. In the pictures here, you can see that one intensivist is performing a tracheostomy at Mount Sinai Morningside, which is our west campus, while being supervised by an intensivist at Mount Sinai Hospital, which is our east campus. The telehealth device used is pictured in the middle. By remotely supervising these procedures, we are able to provide continuous care to patients where they are, rather than transferring them to a larger medical center to receive these procedures. The Institute for Critical Care Medicine also has a vascular access service that triages and coordinates placement of central lines and tunneled catheters, and they are also experts in placement of ultrasound-guided peripheral IVs. The service has three branches, central venous access service, peripheral venous access service, and vascular access service for tunneled catheters. In 2022, the vascular access service performed over 10,000 insertions with temporary catheters placed within 24 hours and 98% of tunneled catheters within two business days of a consult. The efficient placement of tunneled catheters leads to timely discharge, improving overall quality of patient care, and reducing the ICU and overall hospital length of stay. Furthermore, the vascular access service has played an integral role in reducing the number of CLABSIs at Mount Sinai Hospital. The vascular access service has also expanded its scope across the health system to triage tunneled catheter consults at other campuses to ensure they're appropriate and placed in a timely fashion, ensuring their patients are discharged safely and efficiently. Now that we've covered some teams that we use on daily basis, I will next describe the ways in which we've prepared for strain and crisis situation by adapting our everyday processes to meet the needs of our patients. Many hospitals and health systems across the nation have encountered labor disruptions with clinical staff that have temporarily strained regular workflows. But it's safe to say that every hospital has felt the pressure of increased patient volume or disrupted processes during the COVID-19 surges over the last few years. To provide continuous care across the health system, we have prepared for these circumstances by cross-credentialing our faculty and non-union providers so they could provide care at any site and adapt with the level loading of our patients. In these strained and crisis times, we've built off of our strong foundational processes and adapted to meet the needs of the patient volume. The operational adjustment we made to meet these needs included limiting or postponing procedures, allocating providers to particular sites with higher volume, redeploying staff with acute care experience, and being creative with our staffing models, space, and resources. New York City was one of the first epicenters of the COVID-19 pandemic. Our highest surge was in early April 2020. During this time, we expanded our ICU capacity by 121% with the creation of 440 additional ICU beds. During this peak, total COVID patients treated at Mount Sinai Health System were 8,648. There were a lot of fatalities, and the peak COVID census was 2,030 patients, which is 88% of our adult acute care census. We had to close all the programs except for emergency procedures. Once it was clear that normal hospital operations could not continue, we limited all procedures throughout the health system other than emergencies. By limiting these surgeries, we were able to channel all of our resources into caring for our COVID-19 patients, including ICU, med-surg beds, personnel, ventilators, and other equipment. For the purpose of expanding our critical care personnel, faculty and staff from the OR were some of our key players. They already had the basis of acute care expertise that we could build off for our redeployment. We deployed several non-ICU providers to operate in critical care spaces, especially redeployed staff from the operating room. We were able to leverage the acute care knowledge of anesthesiologists as intensivists, intubation team members, and also place vascular access. Our cardiothoracic surgeons played a key role in cannulating patients on ECMO, performing tracheostomy, and delivering critical care. Our OR techs were deployed as a highly successful proning team. Our OR nurses worked alongside our ICU nurses. Even our medical and graduate students played a key role in supplies assembly and distribution and in our laboratories. We are fortunate that there are many non-ICU frontline staff that were committed to stepping out of their comfort zone, learning new topics that were not in their usual day-to-day workflow, and we redeployed where there was a need. A testament of the success was our prone team. Made up of redeployed OR techs and procedural techs, this team won Mount Sinai Hospital's Physician of the Year Team Award in 2020. A field tent was built in Central Park directly outside Mount Sinai Hospital, and on the right, you can see the temporary ICU spaces and double rooms that were created in order to accommodate our patient volume. Every ICU room had two patients. Using HEPA filters, we converted entire units to airborne isolation rooms. Normally, each adult unit has two native airborne isolation rooms. We more than doubled our ICU capacity in under two weeks by designating additional units as ICUs, and by placing two patients into single occupancy rooms, we have 94 licensed beds at Mount Sinai Hospital. It became a 240-ICU bed hospital during the height of the pandemic. We incorporated remote patient monitoring and expanded inpatient telemedicine capabilities to limit exposure to our staff. We also cohorted patients and staff together to minimize exposure. In this picture on the right, you can see all of the white panes. These were the additional pop-up negative pressure rooms with HEPA filters. Our COVID-19 staffing strategy was a modified version of the Society of Critical Care Medicine's recommended model shown here. This is the modified version of the model that we use. An intensivist was able to oversee the care of 24 patients by working with a hybrid team of personnel trained in the ICU and in our critical care courses. We rapidly developed a simulation curriculum for regular and redeployed staff taking care of mock COVID-19 patients, whether it was a centerline placement, intubation, cardiac arrest, and many other different scenarios. Our intensivists usually work 13 shifts a month, so by using this model, we were able to keep their normal shift volume consistent with the intention of curbing burnout. As our patient population increased, we were able to expand our critical care expertise and leverage our newly trained non-ICU providers to deliver the best care possible. The foundation of the Institute for Critical Care Medicine made the process of initiating this workflow seamless. Since our intensivists were already actively working in multidisciplinary teams, they were able to build off their current workflow to expand their patient care. In conclusion, the Institute for Critical Care Medicine has found success in creating teams and processes that expand the critical care footprint and function both inside and outside of the ICUs, centralizing agile patient flow processes that set a strong foundation and can be adapted or scaled and strained in crisis situations, using innovation and technology to our advantage to build a more systemized critical care organization. I encourage you to adapt these concepts to fit your organizational needs. Thank you for your time.

patient flow

critical care organization

ICU beds

coordinated clinical processes

unified critical care staff

centralized governance system