Outcomes 2021 Barlow Respiratory Hospital

Outcomes 2021

In this issue: UPDATES & PUBLICATIONS DISEASE-SPECIFIC CERTIFICATIONS

Master Plan Moves Forward Barlow Respiratory Hospital continued to move forward with our multi-phase Master Plan to ReBuild Barlow as a state-of-the-art modern medical facility.

Throughout construction, and throughout the 2020-2021 COVID-19 pandemic, the hospital has remained fully operational while achieving project milestones.

We have completed seismic reinforcement of our historic 1927 hospital building and renovation of the iconic Guild House.

GUILD HOUSE Built in 1920, the Guild House is an example of adaptive reuse of a historically significant building.

Located on our Los Angeles campus, the Guild House now serves as administrative offices and communications hub. It was originally a dormitory, the Men’s Help House.

Then, from 1975 – 2015, it became known as the Guild House, dedicated to fundraising operations headed by former patients and home of a beloved volunteer-led gift shop featuring hand-crafted items.

SKILLED NURSING FACILITY The hospital has also submitted plans for proposed construction of a 150-bed Skilled Nursing Facility on the campus in Los Angeles. The facility will be designed specifically to meet the needs of patients with chronic critical illness and will specialize in patients with ongoing respiratory conditions. It will be the only skilled nursing facility in the area to serve this unique patient population and will enable Barlow Respiratory Hospital physicians to continue to monitor recovery of medically fragile patients within the hospital’s existing campus.

NEW STATE-OF-THE-ART HOSPITAL Renovation and expansion of the hospital building continues with a projected opening in 2023, following our 120th year of service. This new state-of-the-art hospital will significantly expand capacity on our Los Angeles campus and builds upon the hospital’s legacy of caring for critically ill patients and those in need of expert respiratory care. The new hospital will feature more beds, larger rooms, and added comfort for patients, families, and visitors.

20

BARLOW OUTCOMES BOOK 2021

Dear Colleague, Barlow Respiratory Hospital is proud to present our annual Outcomes Book.

The world landscape continues to change and to be shaped by the pandemic and by dynamic intersections of politics, medicine, and social culture. This publication highlights our unique role in the continuum of adult acute respiratory care, now expanded to include ICU survivors of coronavirus disease 2019 (COVID-19).

Our peer-reviewed report, “Post-COVID recovery: characteristics of chronically critically ill patients admitted to a long-term acute care hospital,” examines the critical role Barlow Respiratory Hospital plays in responding to the COVID-19 crisis. The first long-term acute care hospital (LTCH) to report on post-COVID-19 recovery, Barlow Respiratory Hospital publications underscore the increasingly vital role the LTCH plays in the continuum of care initiated in the acute hospital as an essential step in treatment, rehabilitation, and recovery.

The value of our care is tangible. We embrace the merits of an outcomes-based approach. We measure what matters. The simple act of measuring and reporting our outcomes makes it evident—across all levels of the organization, to patients and families, and to other stakeholders—that these metrics are important.

Transparent reporting of accurate, timely information about patient care reflects our culture of continuous improvement and provides a valuable tool for referring physicians, patients, and families to make informed decisions.

Measuring performance and finding ways to improve or even maintain it is indeed more important than ever in our data-driven culture. What does it mean to be “data-driven?” This term describes a decision-making process which involves collecting data, extracting patterns and facts from those data, and utilizing those facts to make inferences that inform decision-making.

We remain the only not-for-profit LTCH in California. We treat patients referred to us by esteemed medical professionals at the finest hospitals in the region. In the past five years, 175 hospitals in California and beyond have referred patients to Barlow Respiratory Hospital. Our legacy of care for chronically critically ill (CCI) and medically complex patients began in 1902. It has long been our honor and privilege to be entrusted with our patients’ care.

Every day, and at every opportunity, we renew our commitment to treat our patients, their families, and one another with kindness, respect and dignity while all face continued pandemic-related pressures. In addition to meeting the medical needs of our patients, we continue to strive to overcome health inequities to improve overall healthcare for generations to come.

We hope you will find the information included in this edition of our annual Outcomes Book valuable.

We welcome your feedback, questions, and ideas for collaboration. Please contact us at info@barlowhospital.org

Sincerely,

A M IT M O H A N, P H D, FAC H E , FAC M P E P R ES ID ENT & C H I E F E XEC U T I V E O F F I CER

DAVID R. N ELSON , M D M ED IC A L D IREC TOR

WHO WE ARE MISSION: To make a positive difference in the lives of individuals with chronic critical illnesses and complex respiratory conditions in post-acute settings.

VISION: To be the best in the care of individuals with complex respiratory conditions in the post-acute setting.

VALUES: Continuous Improvement—to deliver Collaboration—to improve patient care Efficiency—in clinical services delivery Respect—for patients, families, and coworkers

22

BARLOW OUTCOMES BOOK 2021

Organizational Overview

Center of Excellence, recognized for treating patients with tracheostomies, on and off the ventilator.

Barlow Respiratory Hospital was founded in 1902 by

Barlow Respiratory Hospital is among the nation’s leading

Dr. Walter Jarvis Barlow as the premier sanatorium

long-term acute care hospitals (LTCH) serving the chronically

for the treatment of tuberculosis. In the late 1960s we

critically ill. We are the destination of choice for weaning

transitioned to become a full-service respiratory hospital.

patients from prolonged mechanical ventilation.

To meet greater need in our community, in the 1980s we assumed our current mission to serve as a regional

Patients are referred to Barlow Respiratory Hospital from

specialty hospital for weaning chronically critically ill

hospital intensive care units (ICUs) in the Los Angeles

patients from mechanical ventilation

metropolitan area and beyond. In the past five years, 175 hospitals in California have referred patients to Barlow

At Barlow Respiratory Hospital, patients with complex

Respiratory Hospital. With nearly 300 physicians on

respiratory conditions benefit from the expertise of a

our medical staff and multiple locations in Los Angeles

multidisciplinary medical team of clinicians who specialize

County, our expertise is accessible to patients and families

in pulmonary medicine, critical care medicine, and internal

throughout the region.

medicine and who work in close collaboration with physicians in a variety of medical practice specialties. This

In 2016, Barlow Respiratory Hospital was awarded the

partnership promotes communication and coordination of

Gold Seal of Approval® for Disease-Specific Certification

care, informs treatment decisions and supports patient-

for Respiratory Failure by The Joint Commission, the first

centered goal setting.

hospital on the West Coast to be awarded and among a select few hospitals nationwide to attain this elite

Barlow Respiratory Hospital serves as a clinical training site

certification, renewed in 2021. Barlow’s initial Gold Seal

for respiratory therapy; nursing; physical, occupational and

of Approval® for Disease-Specific Certification for Wound

speech therapy; pharmacy; clinical nutrition; and other allied

Care was awarded by The Joint Commission in 2021, a

health professionals. Educating medical professionals of the

unique achievement for an LTCH in California. Barlow also

future to care for the chronically critically ill is a vital role Barlow

holds the designation as the only West Coast Passy-Muir

plays in our community, and one in which we take great pride.

ONE TEAM ONE GOAL­–BEST OUTCOME: 2021 UPDATE Barlow Respiratory Hospital remained at the forefront of post-ICU critical care in 2021, as our patient population now includes survivors of COVID-19 pneumonia. We have treated over 200 post-ICU COVID patients, with peerreviewed publication of our early experience in October 2020, revised in April 2021. Long-delayed surveys by The Joint Commission for Disease-Specific Certification for both Respiratory Failure and Wound Care were realized in late 2021 with both programs awarded certification. Barlow Respiratory Hospital is committed to providing the highest quality post-acute care for chronically critically ill and medically complex patients.

We serve Los Angeles County with award-winning expertise from three convenient locations that allow patients and families the comfort of access to their home communities.

BARLOW OUTCOMES BOOK 2021

Established Expertise – Volume Matters

Barlow Respiratory Hospital admits and treats more than twice the national percentage of mechanically ventilated patients discharged from long-term care hospitals.

Data Source: Medicare Payment Advisory Committee (MedPAC), March 2021

2020 2011–2020 1988 ­­–2020

2

BARLOW OUTCOMES BOOK 2021

Barlow Respiratory Hospital is a high-volume regional weaning center. Outcome from trauma, surgery, and a variety of other medical conditions has been shown to be positively affected by providing treatment at facilities experiencing a high volume of patients with those conditions. Outcome is influenced by patient volume, with better outcome occurring in high-volume centers. For over four decades, Barlow Respiratory Hospital has focused on serving mechanically ventilated chronically critically ill patients with medically complex conditions. Recognized nationally and internationally for its published outcomes and TIPS© weaning protocol, and well-established expertise, Barlow Respiratory Hospital remains a leader among long-term acute care hospitals.

Total Patients 671 Ventilator Weaning Program 225 Weaning Success Rate 64%

Total Patients Ventilator Weaning Program Weaning Success Rate

8,343 2,882 57%

Total Patients Approximately 23,000 Ventilator Weaning Program 7,140 Weaning Success Rate 53%

BARLOW OUTCOMES BOOK 2021

3

Ventilator Weaning Program More than 50% weaned each year

WEANING SUCCESS RATE

2015

2016

2017

2018

2019

2020

50%

N=268

N=275

N=347

N=305

N=294

N=318

N=225

More than half weaned in less than two weeks

TIME TO WEAN (MEDIAN DAYS) Barlow consistently weans more than half of patients in less than two weeks.

58%

55%

2014

Weaned is defined as a patient being free of invasive mechanical ventilation at least one full calendar day prior to day of discharge.

58% 54%

Barlow consistently liberates more than half of chronically critically ill patients admitted for weaning from mechanical ventilation, with an average wean rate of 59% over the last seven years.

64%

62%

61%

13 12

12

12 11 10

11 DAYS

10

2014

2015

2016

2017

2018

2019

2020

Time to wean is tallied from the day of admission through the last day of ventilator support.

n=164

n=147

n=200

n=168

n=182

n=184

n=143

Days to Wean

4

BARLOW OUTCOMES BOOK 2021

6 Year Median

54%

12 10

2020

10

2019

11

2018

12

2017

12

2016

13

58%

55%

2015

Barlow Respiratory Hospital has consistently weaned more than 50% of patients each year for the past seven years, while maintaining a time to wean of less than two weeks.

58%

2014

PERFORMANCE OVER TIME

64%

62%

61%

N=268

N=275

N=347

N=305

N=294

N=318

N=225

Weaned

Median Days to Wean

BARLOW OUTCOMES BOOK 2021

5

National Comparisons More Weaned

VENTILATOR WEAN RATE

62.2%

Barlow Respiratory Hospital’s ventilator liberation rate is higher compared to both the Pacific Region and the Nation in a national LTCH database.

53.6% 40.2%

Weaning success, inclusion and exclusion criteria as defined by Centers for Medicare and Medicaid Services (CMS) in the Long-term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set - Version 4.0 Data Source: National LTCH Database 2020 Calendar Year

Barlow Respiratory Hospital

INVASIVE MECHANICAL VENTILATION ADMISSIONS

45.5%

Barlow Respiratory Hospital admits and treats a higher percentage of mechanically ventilated patients than the Pacific Region and the Nation when compared in a national LTCH database.

Pacific Region

Nation

More Ventilator Admissions

30%

26.2%

Data Source: National LTCH Database 2020 Calendar Year

Barlow Respiratory Hospital 6

BARLOW OUTCOMES BOOK 2021

Pacific Region

Nation

VENTILATOR WEANING ADMISSIONS

33.2%

Barlow Respiratory Hospital admits and treats a higher percentage of patients for weaning from mechanical ventilation compared to both the Pacific Region and the Nation in a national LTCH database.

Data Source: National LTCH Database 2020 Calendar Year

More Weaning Admissions

24.6%

Barlow Respiratory Hospital

Pacific Region

23.4%

Nation

3.54% HOSPITAL-ACQUIRED PRESSURE INJURIES (HAPI) RATE Barlow Respiratory Hospital has a strikingly lower rate of hospital-acquired pressure injuries compared to both the Pacific Region and the Nation in a national LTCH database.

Data Source: National LTCH Database 2020 Calendar Year

2.35%

Lower is Better

0.52% Barlow Respiratory Hospital

Pacific Region

Nation

BARLOW OUTCOMES BOOK 2021

7

CASE MIX INDEX (CMI) CMI of a hospital reflects diversity, clinical complexity, and the needs for resources in the population of all the patients in the hospital.

A higher CMI indicates a more complex and resource-intensive patient population.

1.371

More Complex

1.294 1.242

Data Source: National LTCH Database 2020 Calendar Year

Barlow Respiratory Hospital

Pacific Region

Nation

Higher Survival Rate

SURVIVAL RATE Despite admitting a more clinically complex patient population, Barlow Respiratory Hospital has a higher percentage of patients survive to discharge compared to both the Pacific Region and the Nation.

86% 79.9%

83.7%

Data Source: National LTCH Database 2020 Calendar Year

Barlow Respiratory Hospital 8

BARLOW OUTCOMES BOOK 2021

Pacific Region

Nation

BARLOW OUTCOMES BOOK 2021

15

Center for Outcomes & Value Barlow Respiratory Hospital maintains the largest longitudinal dataset in the nation with reported outcomes of chronically critically ill (CCI) patients admitted to an LTCH for weaning from prolonged mechanical ventilation.

Established in 1988, the Ventilation Outcomes Dataset (VOD), a performance improvement dataset, includes data on more than 7,000 patients over 33 consecutive years. The advantage of our robust longitudinal dataset is that we can measure change. The dataset allows us to analyze the impact of various processes, protocols, and policies on improvement in patient outcomes.

FIRST IN POST-COVID RECOVERY REPORTING In 2020, Barlow Respiratory Hospital established the Post-COVID Recovery Dataset, now with over 200 patient observations, as our role in treating CCI and medically complex patients expanded to include ICU survivors of coronavirus disease 2019 (COVID-19). Barlow was the first to report patient characteristics of a series of COVID-19 survivors admitted to the post-acute venue of an LTCH, published in October 2020 with revision in April 2021. Updates, including outcomes of weaning from prolonged mechanical ventilation, have been presented at local and international conferences, emphasizing the vital role of the LTCH in responding to the COVID-19 crisis. As these patients continue to require considerable medical interventions and treatment, Barlow plays a critical function in response to COVID-19 infection as an essential step in the continuum of care for treatment, rehabilitation, and recovery.

PUBLICATIONS Hassenpflug MS, Jun D, Nelson DR and Dolinay T. Post-COVID recovery: characteristics of chronically critically ill patients admitted to a long-term acute care hospital [version 2; peer review 2: 2 approved] F1000Research 2021, 9:1241 (first published 15 October 2020) Hassenpflug MS, Jun D, Dolinay T, Nelson DR. Post-COVID recovery: chronically critically ill patients admitted to a long-term acute care hospital. Crit Care Med 2021;49(1):A277 Dolinay T, Jun D, Maller A et al. Quantitative image analysis in COVID-19 acute respiratory distress syndrome: a cohort observational study. [version 1]. F1000Research 2021, 10:1266 (https://doi.org/10.12688/f1000research.75311.1)

PRESENTATIONS COVID-ARDS Post-acute Care. Audio slide presentation, Harbor-UCLA Grand Rounds, May 19, 2021. Virtual conference.

Tamas Dolinay, MD, PhD. Post-COVID Recovery: Characteristics and Outcomes of Chronically Critically Ill Patients Admitted to a Longterm Acute Care Hospital. Audio slide presentation, California Research Forum on Lung Health, April 24, 2021.

Virtual conference. Presentation awarded third place for Original Investigation. Dale Jun, MD Post-COVID Recovery: Characteristics and Outcomes of Chronically Critically Ill Patients Admitted to a Longterm Acute Care Hospital. Audio slide presentation, Society of Critical Care Medicine (SCCM) 50th Critical Care Congress, January 2021. Virtual conference. Dale Jun, MD

10

BARLOW OUTCOMES BOOK 2021

FIRST IN OUTCOMES REPORTING Barlow leads LTCHs in outcomes reporting with over 100 publications – book chapters, peer-reviewed journal articles, editorials and abstracts – and hundreds of national and international conference presentations. Using the ability of the web to track the impact of our work, the data show that other medical authors have cited, or referenced, Barlow publications over 1,000 times.

Our rich history of outcomes research and publication in chronic critical illness and post-acute weaning spans four decades, beginning in the early 1990’s.

First Published Weaning Outcomes. Barlow Respiratory Hospital was the first to publish outcomes of weaning patients from prolonged mechanical ventilation at an LTCH, introducing the concept of a regional weaning center to the pulmonary and critical care community.

First Published Weaning Protocol. Barlow Respiratory Hospital was the first to develop and publish an evidencebased protocol for weaning ventilator-dependent chronically critically ill patients in the post-ICU setting. Our Therapist-Implemented Patient-Specific “TIPS©” protocol has long been the standard of care at Barlow, and is recognized nationwide and abroad, serving as a “best practice” model for weaning patients from prolonged mechanical ventilation.

First Multicenter Study. Barlow Respiratory Hospital served as the leader and primary research site for the first published multicenter study reporting patient characteristics and weaning outcomes of patients admitted to 23 LTCHs nationwide.

THE VALUE OF CARE Outcomes are key components in defining the value of health care. Building on our position at the forefront of LTCH outcomes reporting, Barlow has played an active and vital role in shaping healthcare decisions and establishing national benchmarks for LTCH quality measures.

By engaging in outcomes and health sciences research, Barlow Respiratory Hospital serves as a valuable resource for patients who become ventilator-dependent and have weaning and rehabilitative potential, the chronically critically ill, those with chronic lung and medically complex disease processes, their families, and the medical community entrusted with their care.

BARLOW OUTCOMES BOOK 2021

11

Continuous Improvement We are driven to achieve superior value in the eyes of our stakeholders. We take pride in our work.

We believe that excellence in our delivery of patient care and services distinguishes us from others.

We focus on personal and professional development to promote a culture of safety and provide a systematic, coordinated and continuous approach for creating and maintaining focus on reliable processes and best clinical outcomes.

CHANGES IN SKIN INTEGRITY: PRESSURE ULCER/INJURY RATE Percentage of patients with pressure ulcers/injuries that are new or worsened (Stages 2, 3, 4, and Unstageable) The overall direction of the data is lower (lower is better)

14% 12%

UCL

10% 8% 6% 4%

CL

2%

NOV-15 DEC-15 JAN-16 FEB-16 MAR-16 APR-16 MAY-16 JUN-16 JUL-16 AUG016 SEP-16 OCT-16 NOV-16 DEC-16 JAN-17 FEB-17 MAR-17 APR-17 MAY-17 JUN-17 JUL-17 AUG-17 SEP-17 OCT-17 NOV-17 DEC-17 JAN-18 FEB-18 MAR-18 APR-18 MAY-18 JUN-18 JUL-18 AUG-18 SEP-18 OCT-18 NOV-18 DEC-18 JAN-19 FEB-19 MAR-19 APR-19 MAY-19 JUN-19 JUL-19 AUG-19 SEPT-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20 JUL-20 AUG-20 SEPT-20 OCT-20 NOV-20 DEC-20

0%

C. DIFFICILE RATE PER 10,000 PATIENT DAYS

The overall direction of the data is lower (lower is better)

35.0

UCL

30.0 25.0 20.0

CL

15.0 10.0 5.0

LCL

12

BARLOW OUTCOMES BOOK 2021

Q4 20

Q3 20

Q2 20

Q1 20

Q4 19

Q3 19

Q2 19

Q1 19

Q4 18

Q3 18

Q2 18

Q1 18

Q4 17

Q3 17

Q2 17

Q1 17

Q4 16

Q3 16

Q2 16

Q1 16

Q4 15

Q3 15

Q2 15

Q1 15

0.0

CAUTI (Catheter-associated Urinary Tract Infections) RATE PER 1,000 URINARY CATHETER DAYS The overall direction of the data is lower (lower is better) 7.0

UCL

6.0 5.0 4.0 3.0

CL

2.0 1.0

Q4 20

Q3 20

Q2 20

Q1 20

Q4 19

Q3 19

Q2 19

Q1 19

Q4 18

Q3 18

Q2 18

Q1 18

Q4 17

Q3 17

Q2 17

Q1 17

Q4 16

Q3 16

Q2 16

Q1 16

Q4 15

Q3 15

Q2 15

Q1 15

Q4 14

Q3 14

Q2 14

Q1 14

0.0

CLABSI (Central Line-associated Blood Stream Infections) RATE PER 1,000 CENTRAL LINE DAYS 7.0

Below average rate of infection last two calendar years

6.0 5.0

UCL 4.0 3.0 2.0

CL 1.0

Q4 20

Q3 20

Q2 20

Q1 20

Q4 19

Q3 19

Q2 19

Q1 19

Q4 18

Q3 18

Q2 18

Q1 18

Q4 17

Q3 17

Q2 17

Q1 17

Q4 16

Q3 16

Q2 16

Q1 16

Q4 15

Q3 15

Q2 15

Q1 15

0.0

BARLOW OUTCOMES BOOK 2021

13

Experience of Care Better patient care and family experiences are associated with greater levels of adherence to treatment processes, improved clinical outcomes, and enhanced patient safety. Barlow Respiratory Hospital is committed to providing care that is respectful of and responsive to individual patient preferences, needs and values.

Even during the challenges of the COVID-19 pandemic, Barlow Respiratory Hospital responses to the Experience of Care survey have continued to reflect a high level of satisfaction with care.

Overall, how would you rate your satisfaction with your experience at Barlow?

98% PATIENT AND FAMILY EXPERIENCE OF CARE Overall satisfaction with the experience of care at Barlow Respiratory Hospital was ranked in the top tier by nearly 100% of patients and families.

2%

Data Source: Patient and Family Satisfaction with Care Inpatient Survey Report 2020 Calendar Year

Very Satisfied/ Satisfied

LIKELIHOOD OF RECOMMENDING BARLOW

Other Responses

93%

The likelihood of recommending Barlow was ranked at the top of the scale by over 90% of patients and families.

Data Source: Patient and Family Satisfaction with Care Inpatient Survey Report 2020 Calendar Year

7% Highly Likely 14

BARLOW OUTCOMES BOOK 2021

Other Responses

Barlow Respiratory Hospital Board of Directors Michael D. Berger | CHAIR Diane Naegele | VICE CHAIR Jason Zayon, CPA | SECRETARY/ TREASURER Bradford M. Bolger Carrie Brillstein Earl E. Gales, Jr. Nancy Katayama Eric Kleerup, MD Amit Mohan, PhD, FACHE, FACMPE David R. Nelson, MD Richard Seiden John Van Dyke, MD Daniel Weinstein

IN MEMORY OF

David J. Scheinhorn, M.D., FACP, FCCP

Dr. Scheinhorn passed away in October 2021.

Arriving at Barlow Respiratory Hospital in 1987, Dr. Scheinhorn served as the Medical Director from 1988-1999 and the Director of Research of Barlow Respiratory Research Center from 1991-2006.

BARLOW OUTCOMES BOOK 2021

15

Trusted ~ Proven ~ Award-Winning

With a legacy of care and expertise, Barlow Respiratory Hospital admits and treats patients from all over California, the West Coast, and beyond. If you have a patient who requires the experience and expert care only Barlow can offer, contact us today. With locations in Los Angeles, Van Nuys, and Whittier we are accessible to patients’ home communities.

Admissions and Referrals Info Line: 213-202-6878 Toll Free: 833-4-BARLOW www.barlowhospital.org

12

LOS ANGELES

VAN NUYS

WHITTIER

2000 Stadium Way

15107 Vanowen St.

12401 E. Washington Blvd.

Los Angeles, CA 90026

Van Nuys, CA 91405

Whittier, CA 90602

BARLOW OUTCOMES BOOK 2021