The impact of an accountable care unit on mortality: an observational study

Figures & data

Figure 1. Risk-adjusted yearly inpatient mortality odds-ratio versus pre-intervention for 5 years on an accountable care unit. Shaded area denotes the period of most intensive unit-level innovation and corresponding risk-adjusted mortality reduction

Table

	Pre	Year 1	Year 2	Year 3	Year 4	Year 5
Unit Inpatients	1958	2169	2139	2148	1933	1811
Mortality, n (%)	41 (2.1%)	35 (1.6%)	27 (1.3%)	30 (1.4%)	38 (2.0%)	41 (2.3%)
p-value*	NA	0.22	0.03	0.06	0.45	0.93
aOR (95% CI)*	1.0	0.76 (0.48–1.20)	0.58 (0.35–0.94)	0.64 (0.39–1.03)	0.85 (0.54–1.34)	1.0 (0.64–1.56)
Unit Innovations
Structured Work	x	SIBR for ~50% of unit patients
	x	Case reviews†	Team to Bedside for acutely unstable patients
Leadership	x	Unit leaders meet weekly to strategize and review data
	x	Weekly leader rounding			Monthly leader rounding
Hospital-wide Innovations
Patient Rescue Paged Alerts	Modified Early Warning System (MEWS) launched Q4 2011
	x	x	x	Severe Sepsis Alert
Culture of Safety	x	x	x	x	High Reliability Organization training

aOR = Adjusted Odds Ratio, CI = Confidence Interval, NA = Not applicable, x = no innovation for given time period

*Logistic regression adjusted for age, chronic liver disease, chronic heart disease, and malignancy.

†Example case: 2/20/14 a newly diagnosed Type 1 diabetic was admitted to the unit with holding orders and found by bedside nurse to be minimally responsive. The nurse paged the medical team three times for fluctuating blood sugars and multiple seizures; it took over an hour to transfer patient to the intensive care unit. Intentional case review informed unit-level protocols and innovations.

Figure 2. Unexpected deaths among inpatients. Unexpected deaths were those without a documented ‘comfort care’ plan

Table

Medical A Inpatients, excluding comfort care	Pre-intervention	Year 1	Year 2	Year 3	Year 4	Year 5
Alive	1848	2070	2059	2056	1829	1709
Deceased	7	5	3	0	2	2
Total	1855	2075	2062	2056	1831	1711
Percent	0.38%	0.24%	0.15%	0.00%	0.11%	0.12%

Table

ACU	Accountable Care Unit
aOR	adjusted Odds Ratio
MEWS	Modified Early Warning System
NA	Not Applicable
OR	Odds Ratio
sd	Standard Deviation
SIBR	Structured Interdisciplinary Bedside Rounds