Methodist Le Bonheur Healthcare Research Articles

A Healthcare System Looks Within to Improve Outcomes.

Healthcare organizations are facing exponential growth in change-not just to compete, but to survive. Amid the widening gap between expenses and reimbursements, hospitals must manage the adoption of expensive advanced technologies, continuous synthesis of emerging clinical knowledge, intensive regulatory readiness, and public ranking of quality outcomes. And they must handle all this as patient expectations grow. At Methodist Le Bonheur Healthcare (MLH), we have approached these challenges by nurturing an organizational mindset of transformational innovation. The ability to harness the collective brainpower of 12,000 MLH associates to find cost reductions, operational efficiencies, and better ways to provide patient care has proven invaluable when facing the demands to do more with less. Achieving this degree of engagement began with full transparency of the challenges we face as an organization, clearly articulating the need to change, and providing a structured approach to capture and respond to suggestions from the workforce. The Power of One Idea program, a platform for listening and learning, has enabled the workforce to answer that call and make an impressive impact: $17 million in cost savings and previously untapped revenues. In return, the forward-thinking associates submitting those ideas have shared in those savings and realized more than $1.5 million in extra income. The Performance Excellence Award, a program to seek out best practices in safety, efficiency, or effectiveness, also has enriched the business with at least 100 proven approaches to advance care delivery.

The efficacy and cost-impact of rasburicase 3 mg versus 6 mg for the management of tumor lysis syndrome: A multicenter analysis.

Purpose: Hyperuricemia is a complication arising from tumor lysis syndrome (TLS). Literature has shown that a single 3 mg dose was just as efficacious as a single 6 mg dose when the uric acid (UA) levels were ≤12 mg/dL. Here, we present a multi-center analysis rasburicase utilization and its effect on healthcare costs. Methods: This is a multi-center, retrospective analysis of adult cancer patients who were admitted to Methodist Le Bonheur Healthcare hospitals and received rasburicase from February 2020 to February 2021. The primary endpoint was to test whether rasburicase 3 mg had similar rates of uric acid normalization (defined as uric acid ≤7.5 mg/dL) within 24 h as a dose of 6 mg. Results: Seventy-nine patients were included in the study. While the baseline uric acid was lower in the 3 mg arm compared to the 6 mg arms, there was no difference in the uric acid normalization at 24 h between the 3 mg arm (95%) and 6 mg arm (82%) (p = 0.134). A cost-savings of over $300,000 annually can be achieved with the proposed protocol. Conclusion: A single, fixed rasburicase dose of 3 mg was effective in normalizing uric acid levels within 24 h, and is associated with significant cost-savings.

B-PO05-095 USE OF RADIOFREQUENCY ABLATION CATHETER IN CRYOBALLOON PULMONARY VEIN ISOLATION - A TWO HOSPITAL SYSTEM LOCAL EXPERIENCE

Pulmonary vein isolation (PVI) with catheter ablation is a preferred method for symptom and rhythm control in patients with atrial fibrillation (AF). Both Cryoballoon and radiofrequency (RF) ablation are commonly used to achieve PVI. Prior studies have suggested that approximately 14.1 % of Cryoballoon ablation also require RF catheter to complete PVI. To assess the usage of RF catheter in our hospital system for cases where cryoballoon ablation was used as primary approach for PVI. We performed a retrospective analysis of 378 patients with either paroxysmal or persistent AF who underwent PVI at two Methodist LeBonheur Healthcare system hospitals in Memphis TN from January 2013 to June 2020. Patient demographics and PVI procedure details were obtained using electronic medical records. Data was compiled using Redcap and statistical analysis was performed using SPSS version 27. A total of 167 AF patients underwent cryoballoon ablation as a primary approach. 127 patients had paroxysmal AF, 37 patients had persistent AF, 2 patients had longstanding persistent AF and one AF type was not classified. The mean age was 61.7 +/- 11 years and there were 112 males (67.1%). In 62 patients (37.1%) RF ablation was required to complete PVI. In additional 44 patients (26.4%), RF catheter was used to perform additional linear or complex fractionated atrial electrograms ablations during an index procedure. The total usage of RF catheter was 63.5% in the index Cryoballoon AF ablation. In this study of our hospital system comprising of two hospitals performing AF ablation, RF ablation was employed in a majority of patients where cryoballoon ablation was the primary approach.

Comparison of Nafcillin and Cefazolin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteremia

Traditionally, the antibiotic of choice for Methicillin-susceptible Staphylococcus aureus related blood stream infections (MSSA-BSI) are the antistaphylococcal penicillins. Cefazolin is considered an alternative agent, with recent evidence showing similar clinical efficacy. This study further evaluates the utility of nafcillin versus cefazolin in MSSA bacteremia including high disease burden sources of infection and its impact on treatment failure. This retrospective study included patients admitted to Methodist LeBonheur Healthcare adult hospitals from 2011 to 2016. Patients were included if they received at least 3 days of either nafcillin or cefazolin and had a positive blood culture for MSSA. The primary objective was to evaluate rates of treatment failure between groups. Secondary outcomes included clinical and microbiological cure, MSSA-BSI associated readmissions, identification of risk factors for treatment failure including disease burden, in-hospital and 90 day mortality. A total of 277 patients were included (nafcillin n=126; cefazolin n=151). Treatment failure and microbiologic cure were similar between nafcillin and cefazolin (20.6% vs. 16.6%; 91.2% vs. 87.2%, respectively). Clinical cure was significantly higher in the cefazolin treatment arm (93.4 vs. 83.3%; P=0.012). However, the total number of patients with high disease burden was greater in the nafcillin group (54.8% vs. 39.1%; P=0.011). Higher rates of in-hospital mortality were observed in the nafcillin group (15.1% vs. 6%; P=0.016). Our study observed significantly higher rates of clinical cure and reduced in-hospital mortality in patients who received cefazolin. Further analysis is warranted to evaluate the effectiveness of these agents and identifying predictors of treatment failure.

76 Airway Complications in Angioedema

Angioedema is a common and potentially life-threatening diagnosis that results in more than one million emergency department (ED) visits per year. It manifests as localized edema of the deep dermis and subcutaneous tissues secondary to increased vascular permeability. The face, lips, mouth, throat, and extremities are commonly affected. The pathophysiology is complex and the disorder is broadly classified as resulting from histaminergic or bradykinin-mediated mechanisms. Angioedema is a well-known adverse effect of angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitor-induced angioedema (AIAA) affects 0.1% to 0.7% of patients taking ACE inhibitors and accounts for approximately one-third of all ED visits for angioedema in the United States. Early ED provider recognition of the specific type of angioedema is essential to optimize management and patient outcomes. We sought to characterize airway interventions and complications for AIAA versus non-ACE inhibitor induced angioedema (NAIA). We performed a retrospective chart review of patients seen in the ED with a diagnosis of angioedema at Methodist LeBonheur Healthcare facilities in Memphis, TN from 1 January 2006 to 31 August 2016. Adult patients greater than 18 years were included. Among the 1,299 patients diagnosed with angioedema, 954 had AIAA and 345 had NAIA. AIAA patients were older than those with NAIA (59 years vs 55; p=0.01). Approximately 62% were female in both groups. AIAA patients were more likely to be African American (89% vs 76%; p=0.001) and more likely to be current smokers (28% vs 21%; p=0.001). BMI distribution was similar between the two groups. Initial symptoms were similar in the 2 groups except rash (<1% in AIAA group vs. 8% in NAIA group; p<0.0001) and face swelling (42% and 32% respectively; p=0.01). Anaphylaxis and shock on presentation was much more common in the NAIA group (p<0.0001). Patients with AAIA required intubation significantly more frequently (19.8% vs 12.2%; p=0.03) and had a higher likelihood of difficult intubation (50.8% vs 40.4%; p=0.04). One-third of patients who required intubation in the AAIA group required nasotracheal intubation (NAIA, 16%; p=0.02). Patients with AAIA were intubated by Otolaryngology much more frequently as compared to NAIA (30% vs 9%; p=0.002). Rates of emergency cricothyroidotomy and semi elective tracheostomy were similar in both groups. Extubation failure rates were also similar, with approximately 8% failing extubation once and 2.4% failing twice. In multivariate analysis, patients with AAIA were more likely to be African American (OR 3; p=0.007), currently smoke (OR 1.5; p=0.021), and have lip swelling (OR 2.5; p=0.017). They were less likely to have rash (OR 0.089; p=0.0001) and anaphylaxis (OR 0.032; p=0.016). Airway complications occurred more commonly in patients suffering from AAIA. This population is more likely to need intubation, be difficult to intubate, and require advanced airway techniques such as nasotracheal intubation.

75 Association of Supraglottic or Glottic Edema With Upper Aerodigestive Tract Edema

Angioedema is a life-threatening diagnosis that results in more than one million emergency department (ED) visits per year and is a well-known adverse effect of angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitor-induced angioedema (AIAA) affects 0.1% to 0.7% of patients taking ACE inhibitors and accounts for approximately one-third of all ED visits for angioedema in the United States. Some studies have suggested that patients who have isolated lip or face edema are at low risk for airway interventions. However, other studies suggest that absence of upper aerodigestive tract edema may not reliably rule out laryngeal or glottic edema. The current literature is similarly conflicting with regard to the role of etiology in disease severity. We sought to determine the association between supraglottic or glottic edema with upper aerodigestive tract, lip and face edema in patients with AIAA. We performed a retrospective chart review of ED patients diagnosed with angioedema at Methodist LeBonheur Healthcare facilities in Memphis, TN from 1 January 2006 to 31 August 2016. Only patients greater than 18 years who underwent fiberoptic evaluation after diagnosis of AIAA were included in the final analysis. Among the 1,299 patients with angioedema, 954 were diagnosed with AIAA. Of these, 755 underwent fiberoptic evaluation. Mean age of patients with AIAA was 59 years, about 60% were female and 90% were African American. Four hundred thirty-four patients had lip swelling, 118 had soft palate swelling, 362 had anterior tongue swelling, 119 had floor of mouth swelling, 148 had base of tongue swelling and 89 had glottic or supraglottic swelling. Among patients who did not have lip swelling (321), 15% had glottic or supraglottic swelling evident on exam. Similarly, among patients who did not have anterior tongue swelling (393) or base of tongue swelling (607), 6% and 5.5% had supraglottic and/or glottic swelling, respectively. Supraglottic or glottic edema predicted need for intubation (OR 125; p=0.0001). In multivariate analysis, presence of soft palate swelling (OR 4; p=0.03) and base of tongue edema (OR 4.5; p=0.02) increased the likelihood of supraglottic or glottic edema on exam. However, there was no significant correlation between lip swelling (r= -0.09 ), soft palate swelling (r=0.3), anterior tongue swelling (r=0.18), floor of mouth swelling (r=0.32) or base of tongue swelling (r=0.39) with supraglottic or glottic swelling. This is a large study of patients with AAIA who underwent fiberoptic exams. Our study suggests that a significant portion of patients without upper aerodigestive tract swelling may still have supraglottic or glottic swelling. Since supraglottic and/or glottic swelling is considered a significant risk factor for predicting airway interventions, physicians should not use absence of upper aerodigestive tract swelling to reliably predict absence of supraglottic and/or glottic swelling.

Michael O. Ugwueke, DHA, FACHE, President and CEO, Methodist Le Bonheur Healthcare.

Michael O. Ugwueke, DHA, FACHE, President and CEO, Methodist Le Bonheur Healthcare.

Pharmacologic Treatment of Alcoholic Hepatitis: Examining Outcomes Based on Disease Severity Stratification

Maddrey discriminant function (MDF) score is a measure of disease prognosis in alcoholic hepatitis (AH) used to identify patients at highest risk of mortality and determine the need for initiation of pharmacologic treatment. The purpose of this study was to evaluate the effects of pharmacologic therapy for hospitalized AH patients as stratified by MDF score. A retrospective review of patients with an AH diagnosis admitted to a Methodist LeBonheur Healthcare adult hospital between 06/2009 and 06/2014 was conducted. Patients ≥18 years of age with an ICD-9 code for AH were evaluated. Of the 493 patients screened, 234 met the inclusion criteria, comprised of 62 patients with an MDF≥32 (treatment, n=42 vs. no treatment, n=20) and 172 patients with an MDF<32 (treatment, n=15 vs. no treatment, n=157). For the patients with an MDF≥32, there was no statistically significant difference between the treatment group vs. non-treatment group regarding 28-day mortality (31% vs. 11%, respectively; P=0.18) and 6-month mortality (45% treatment vs. 38% non-treatment; P=0.75). For the patients with an MDF <32, there was no statistically significant difference between the treatment group vs. non-treatment group regarding 28-day mortality (0% vs. 7%, respectively; P>0.99) and 6-month mortality (11% treatment vs. 13% non-treatment; P>0.99). There was no difference in incidence of acute kidney injury, hepatorenal syndrome, development of infection or hepatic encephalopathy between the treatment vs. non-treatment groups. Pharmacologic treatment showed no survival benefit, regardless of disease severity. Given the mortality risk seen in mild-moderate AH patients not receiving treatment and concern for a possible treatment ceiling effect in severe AH patients, more data are needed to adequately assess the utility of MDF in selecting appropriate candidates for AH treatment.

Treatment of Acute Hepatic Encephalopathy

Objectives: Rifaximin is approved for the reduction of hepatic encephalopathy (HE) recurrence in patients with chronic liver disease (CLD); however, few studies have evaluated the benefit of adding rifaximin to lactulose for treatment of acute HE. The aim of this study was to determine the impact of combination therapy with lactulose and rifaximin on hospital length of stay (LOS) and readmission rates. Methods: A retrospective study of patients admitted to an adult hospital within the Methodist LeBonheur Healthcare (MLH) System in Memphis, Tennessee, between 2007 and 2012 was conducted. Patients were identified via International Classification of Diseases, Ninth Revision (ICD-9) coding for liver cirrhosis. Results: Of the 173 patients included, 87 (50%) received lactulose monotherapy and 62 (36%) combination therapy, while 24 (14%) underwent therapy escalation. Median LOS was 6 days in monotherapy group and 8 days in combination group (P = .9). At 180 days, patients receiving combination therapy had fewer readmissions for HE than those receiving monotherapy (2.4% vs 16.2%, P = .02). Conclusion: Addition of rifaximin to lactulose for treatment of acute HE did not reduce hospital LOS; however, it did result in lower readmission rates for HE at 180 days.

Utilization of Hot Spotting to Identify Community Needs and Coordinate Care for High-Cost Patients in Memphis, TN

In 2006, Methodist Le Bonheur Healthcare (MLH) created the Congregational Health Network (CHN, TM pending) which works closely with clergy in the most under-served zip codes of the city to improve access to care and overall health status of the population. To best coordinate CHN resources around high-utilization and address the largest health needs in the community, MLH applied hot spotting and geographic information system (GIS) spatial analysis techniques. These techniques were coupled with the community health needs assessment process at MLH and qualitative, participatory research findings captured in collaboration with church and other community partners. The methodology, which we call “participatory hot spotting,” is based upon the Camden Model, which leverages hot spotting to assess and prioritize community need in the provision of charity care, but adds a participatory, qualitative layer. In this study, spatial analysis was employed to evaluate hospital-based inpatient and outpatient utilization and define costs of charity care for the health system by area of residence. Ten zip codes accounted for 56% of total system charity care costs. Among these, the largest zip code, as defined by a percentage of total charity costs, contributed 18% of the inpatient utilization and 17% of the cost. Further, this zip code (38109) contributed 69% of the inpatient and 76% of the outpatient charity care volume and accounted for 75% of inpatient and 76% of outpatient charity care costs for the system. These findings were combined with grassroots intelligence that enabled a partnership with clergy and community members and Cigna Healthcare to better coordinate care in a place-based population health management strategy. Presentations of the analytics have subsequently been made to HHS and the CDC, referred to by some as the “Memphis Model”.

A Physician Hospital Organization's Approach to Clinical Integration and Accountable Care

A Physician Hospital Organization's Approach to Clinical Integration and Accountable Care

Using Portfolios to Introduce the Clinical Nurse Leader to the Job Market

Development of a portfolio is an effective strategy used by clinical nurse leaders (CNLs) to inform prospective employers of their specialized skills in quality improvement, patient safety, error prevention, and teamwork. The portfolio provides evidence of competence relative to the role of clinician, outcomes manager, client advocate, educator, information manager, systems analyst/risk anticipator, team manager, healthcare professional, and lifelong learner. This article describes the CNL portfolio developed by experts from the University of Tennessee Health Science Center and Methodist LeBonheur Healthcare. Examples of portfolio documents generated throughout the master's entry CNL curriculum are provided, along with student experiences using the portfolio in the employment interview process.

The Life of Leaders: An Intensive Health Program for Clergy

Clergy suffer from chronic disease rates that are higher than those of non-clergy. Health interventions for clergy are needed, and some exist, although none to date have been described in the literature. Life of Leaders is a clergy health intervention designed with particular attention to the lifestyle and beliefs of United Methodist clergy, directed by Methodist LeBonheur Healthcare Center of Excellence in Faith and Health. It consists of a two-day retreat of a comprehensive executive physical and leadership development process. Its guiding principles include a focus on personal assets, multi-disciplinary, integrated care, and an emphasis on the contexts of ministry for the poor and community leadership. Consistent with calls to intervene on clergy health across multiple ecological levels, Life of Leaders intervenes at the individual and interpersonal levels, with potential for congregational and religious denominational change. Persons wishing to improve the health of clergy may wish to implement Life of Leaders or borrow from its guiding principles.

Building a Partnership to Address Violence in Three Historically Colonised Contexts: Report on Research Meeting in Memphis

This report provides an overview of a research visit and planning meeting held at the Methodist LeBonheur Healthcare (MLBH) in Memphis, Tennessee, United States of America (US) in December 2008. The purpose of this meeting was for the invited participants to plan a longitudinal study around the working title: 'Understanding the positive mediating influences of faith, religion and spirituality on self-inflicted and interpersonal violence involving males in contexts of historical trauma: An inter- and intra-city comparison in South Africa and United States of America'.

Using Nurse Leader Development to Improve Nurse Retention and Patient Outcomes

With many factors converging, it is critical that nurse leaders have the knowledge and competency to develop outstanding relationships with registered nurses in order to retain them and thus improve patient outcomes. Senior nurse leaders of Methodist Le Bonheur Healthcare, a 7-hospital system based in Memphis is addressing these issues through a comprehensive leader development framework. Through organizational commitment and supported by a federal grant, a program that focuses on creation of individual development plans, provision of development education, and one-to-one on-site coaching has been implemented.

NURSING AGAINST THE ODDS

Senior Vice President and Chief Nurse Executive, Methodist LeBonheur Healthcare, Memphis, Tenn, Clinical Associate Professor, The University of Alabama in Huntsville. [email protected].