Vyaire Respiratory Knowledge Portal

Accountable care organizations are incented to provide higher quality care at a lower total cost. This represents a big change compared to the old system that encouraged hospitals to increase revenues by performing a high volume of procedures.
Hospitals are no longer reimbursed for treatment of most healthcare-associated infections. Value-based purchasing rewards hospitals that achieve clinical and patient satisfaction metrics—at the expense of those that do not.
Regulatory pressures, such as ventilator-associated event reporting and meaningful use, also create new work and may result in lower revenues.
Frontline clinicians are spending more and more time documenting their work and have less time left to focus on patients.

The result? Hospitals and health systems have an increasing urgency to eliminate waste and inefficiency from the care delivery process in order to improve outcomes and lower the cost of care.
So that’s a financial problem. Let’s talk a little bit about how that relates to the clinical problem and the clinical goals that hospitals have. One of the opportunities, one of the neat things about this analytics and mechanical ventilation is that the clinical goals and the financial goals in ventilation are perfectly aligned. The best clinical thing to do for a patient is to get them off the vent breathing on their own as quickly as possible. The best financial thing to do is to get them off the vent breathing on their own as quickly as possible. And there are really only three goals in mechanical ventilation, it’s a complex clinical therapy with complex patients but the goals are simple. It’s to provide life support, prevent or at least reduce patient harm, and minimize time on vent.

1. Vyaire Critical Care Products & Respiratory Knowledge Portal Providing actionable information to help clinicians improve patient care. 1

2. The situation t oday Hospitals and health s ystems u nder p ressure 2 © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

3. An ideal o pportunity Aligned clinical and financial goals 3 © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

4. A focus on mechanical ventilation 4 © 2015 CareFusion Corporation or one of its affiliates. All rights reserved. 3% of patients 1 7 % of days 1 12% of cost 1 Mechanically ventilated patients in US acute care hospitals 36% of patients 2 58% of days 2 72% of cost 2 Mechanically ventilated patients in US intensive care units Medicare DRG 207 patients Per patient average revenue: Average cost of care: $31,405 3 $37,585 3 ($6,180) x 200 patients ($6,180) 3 Loss per patient: ($1.2 million)

5. The key to reducing c osts: Reducing clinical p rocess v ariability Nursing : Performs sedation vacations (SAT ) at least once per day Respiratory: Performs spontaneous breathing trials (SBT) and manages the vent Infection Prevention: Identifies and manages ventilator associated events (VAE) Physicians : Make decisions based on SAT and SBT results © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

6. An ideal o pportunity: Cost of m echanical v entilation It’s costing you a lot – but not because of the equipment 4 © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

7. Meet Dolores 68 Y/O Female COPD, Insulin-Dependent Diabetic Develops Pulmonary Infection Admitted to ICU and Intubated © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

8. Best expected o utcome: Dolores spends 6 days on a ventilator © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

9. Dolores i s n ot a lone How much is being wasted every day? © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

10. The Result Improvements in Outcomes and Costs Dolores can go home sooner ICU frees up one bed Hospital is more profitable © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

11. Actionable Information Bringing multi-disciplinary teams into sync Nursing: Improved compliance with the ICU Sedation protocol Respiratory: Improved compliance with protocols related to weaning, lung protection and alarm settings. Infection Prevention: Identify patients at risk of VAE before they are reportable with no manual data collection. Physicians: Actionable information on ventilation and sedation, and VAE during multi-disciplinary rounds Entire Care Team: Improved coordination, communication and collaboration between care team members

12. The Solution: CareFusion Respiratory Knowledge Portal © 2014 CareFusion Corporation or one of its subsidiaries. All rights reserved.

13. Respiratory Knowledge Portal What is RKP? An analytics and reporting tool that enables hospitals to measure clinical and process variability in ventilator therapy by providing actionable information to help improve patient care Reporting capabilities focus on ventilator weaning lung protective strategies alarm policy compliance VAE surveillance sedation analytics Works with our EMR ( Meditech )

14. RKP Control costs by improving outcomes Hospital Goals and Pressures Clinical Reducing time on vents and related complications Patient safety Regulatory VAC surveillance and CDC reporting; meaningful use mandates Alarm compliance (NPSG 06.01.01) Operations spending less time documenting and more on patient care Less time spent on VAE surveillance/ can focus on other surveillance activities Financial Reducing cost of care

15. Clinical Weaning Monitoring patient with set markers to ensure weaning is implemented timely Less time on vent means Less vent related complications Less time in ICU bed Less time in hospital Less COST to hospital

16. Missed Opportunities

17. Sedation Optimization Currently have protocol in place to facilitate targeted sedation Anecdotally, there have been variations in practice between nurses and physicians. Currently measuring compliance to daily sedation vacations and observing for patterns

18. Sedation

19. Regulatory VAE Surveillance and Reporting Replaces VAP reporting in adult patient Effective January 2013 Three new reportable events VAC, IVAC, Possible or probable VAP VAC based on daily minimum PEEP or FiO2 - Current practice Time intensive Retrospective (week behind) Mandatory reporting to CDC will occur in 2017

20. Regulatory Sedation Analytics Monitoring sedation to ensure patients are not overmedicated and can be weaned timely Alarm compliance NPSG Improved safety on ventilator

21. VAE Surveillance Automated accumulation of data direct form the ventilator Less time getting data equals more time solving the problem Applies the CDC Algorithm Allows 48 hours to correct any VAE’s that can be corrected

22. VAE Surveillance

23. References How Ventilator Data and Analytics Started Mission Regional Medical Center on a Journey of Continuous Quality Improvement: Variability Identified and Addressed, Susan Barlow, MHA, RRT-NPS, CPFT, CPHQ, Respiratory Therapy Vol. 9 No. 1 􀂄 February - March 2014 PG 24-25 Cook, C. Economics of mechanical ventilation and respiratory failure. Crit Care Clin , January 2012, 28(1):39–55. Zilberberg , M., Luippold , R., Sulsky , S., Shorr , A. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States. Critical Care Med, March 2008, 36(3):724–730. Survey : Seven hospitals with an average of 400 beds and 40 ventilators. CareFusion , Summer 2012. Awissi , D., Bégin , C., Moisan , J., Lachaine J. et al. I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann Pharmacother , January 2012, 46(1):21-28. Barr, J., Fraser, G., Puntillo , K., Ely, E. et al. Clinical practice guidelines for the management of pain , agitation, and delirium in adult patients in the Intensive Care Unit: executive summary. Am J Health Syst Pharm, January 2013, 70(1):53–58. Hughes , C., Girard, T., Pandharipande , P . Daily sedation interruption versus targeted light sedation strategies in ICU patients. Crit Care Med, September 2013, 41(9 Suppl 1):S39–S45. Institute for Healthcare Improvement (IHI ). IHI Ventilator Bundle: Daily “Sedation Vacations” and Assessment of Readiness to Extubate . 2014. Retrieved on July 29, 2014, from: http://www.ihi.org/knowledge/Pages/Changes/ DailySedationVacationsandAssessmentofReadinesstoExtubate.aspx. 23

24. Thank you. 24

25. Disclosures Randy Clare is employed by Vyaire Medical