Multihospital System Research Articles

Abstract NS25: Alteplase Administration in the Very Elder

Background /Purpose: The highest rate of first time strokes occurs in those 80 years and older. Despite the higher stroke rates, increased incidence of atrial fibrillation and often increased severity of stroke in the very elderly, initial clinical trials related to intravenous alteplase did not recruit patients over 80 years of age. Newer evidence supporting use of Alteplase in the very elder recommends that age alone should not be a contraindication for administering alteplase and urges that the risks and benefits be carefully weighed. Additional evidence concludes that although elderly patients have a higher mortality rate and poorer functional outcomes, this finding is consistent with the natural course of aging and treatment benefit may be realized. The purpose of this multihospital system retrospective review is to examine data in patients who received alteplase with the hypothesis that elders greater than 80 years benefited just as much from treatment when compared to those less than 80. Methods: Retrospective data collected at a large Midwestern hospital system compared alteplase administration in patients greater than 80 years of age to patients less than 80. Data examined included initial NIHSS, symptomatic hemorrhage rates, discharge disposition, and incidence of atrial fibrillation. Results: Comparisons (> 80 years vs. < 80 years) revealed: 1) 34% of patients treated with alteplase were greater than 80 years, 2) symptomatic hemorrhage rates were not statistically different (13% vs 8%, p=0.1904), 3) negative discharge outcomes (destination other than home or acute rehab) were more prevalent in the elder population (48% vs. 19%, p< .0001), 4) atrial fibrillation was more prevalent in elders (53%). Conclusions: Despite newer evidence, reluctance among practitioners to administer alteplase to the very elderly persists. In very elderly patients, retrospective data findings indicated that hemorrhage rates were not increased but short-term discharge outcomes were negatively impacted. This may be the result of the aging process and multiple comorbidities. Evaluation and dissemination of findings will emphasize to providers that this vulnerable population may still benefit from alteplase treatment.

Predicting Non-Adherence with Outpatient Colonoscopy Using a Novel Electronic Tool that Measures Prior Non-Adherence.

Accurately predicting the risk of no-show for a scheduled colonoscopy can help target interventions to improve compliance with colonoscopy, and thereby reduce the disease burden of colorectal cancer and enhance the utilization of resources within endoscopy units. We aimed to utilize information available in an electronic medical record (EMR) and endoscopy scheduling system to create a predictive model for no-show risk, and to simultaneously evaluate the role for natural language processing (NLP) in developing such a model. This was a retrospective observational study using discovery and validation phases to design a colonoscopy non-adherence prediction model. An NLP-derived variable called the Non-Adherence Ratio ("NAR") was developed, validated, and included in the model. Patients scheduled for outpatient colonoscopy at an Academic Medical Center (AMC) that is part of a multi-hospital health system, 2009 to 2011, were included in the study. Odds ratios for non-adherence were calculated for all variables in the discovery cohort, and an Area Under the Receiver Operating Curve (AUC) was calculated for the final non-adherence prediction model. The non-adherence model included six variables: 1) gender; 2) history of psychiatric illness, 3) NAR; 4) wait time in months; 5) number of prior missed endoscopies; and 6) education level. The model achieved discrimination in the validation cohort (AUC= =70.2 %). At a threshold non-adherence score of 0.46, the model's sensitivity and specificity were 33 % and 92 %, respectively. Removing the NAR from the model significantly reduced its predictive power (AUC = 64.3 %, difference = 5.9 %, p < 0.001). A six-variable model using readily available clinical and demographic information demonstrated accuracy for predicting colonoscopy non-adherence. The NAR, a novel variable developed using NLP technology, significantly strengthened this model's predictive power.

A Multi-Theoretical Approach to Examining Local Multihospital System Forms

Local multihospital systems, including systems entirely contained within a single market as well as sub-systems of larger regional and national hospital- based organizations, are prevalent and domi...

Tides of change: improving glucometrics in a large multihospital health care system.

This study explores the relationship between education for inpatient diabetes providers and the utilization of insulin order sets, inpatient glucometrics, and length of stay in a large health care system. The study included patients with and without the diagnosis of diabetes. An education campaign included provider-directed diabetes education administered via online learning modules and in-person presentations by trained individuals. Relationships among provider-attended diabetes education, order set usage, and inpatient glucometrics (hypo- and hyperglycemia) were analyzed, as well as length of stay. Insulin use knowledge scores for all providers averaged 52%, and improved significantly to 93% (P < .001) by the end of the education intervention period. Likewise utilization of electronic basal-bolus order sets increased from a baseline of 20% for patients receiving insulin to 86% within 6 weeks (P < .01) of introduction of order sets. During the study, the incidence of hypoglycemia and hyperglycemia declined from 1.47% to 1.27% and from 23.21% to 17.80%, respectively. However, these improvements were not sustained beyond the completion of the education campaign. Education of diabetes health care providers was provided in a large, multihospital system through the use of online learning modules. Adoption of standardized insulin order sets was associated with an improvement in glucometrics. This educational and quality initiative resulted in overall improvements in insulin knowledge, adherence to recommended order sets, inpatient glucometrics, and patient length of stay. These improvements were not sustained, reinforcing the need for repeated educational interventions for those involved in providing inpatient diabetes care.

Implementation of a simple electronic transfusion alert system decreases inappropriate ordering of packed red blood cells and plasma in a multi-hospital health care system

Background and objectivesPrescriber adherence to institutional blood component ordering guidelines can be low. The goal of this study was to decrease red blood cell (RBC) and plasma orders that did not meet institutional transfusion guidelines by using data within the laboratory information system to trigger alerts in the computerized order entry (CPOE) system at the time of order entry. MethodsAt 10 hospitals within a regional health care system, discernment rules were created for RBC and plasma orders utilizing transfusion triggers of hemoglobin <8 gm/dl and INR >1.6, respectively, with subsequent alert generation that appears within the CPOE system when a prescriber attempts to order RBCs or plasma on a patient whose antecedent laboratory values do not suggest that a transfusion is indicated. Orders and subsequent alerts were tracked for RBCs and plasma over evaluation periods of 15 and 10 months, respectively, along with the hospital credentials of the ordering health care providers (physician or nurse). ResultsAlerts triggered which were heeded remained steady and averaged 11.3% for RBCs and 19.6% for plasma over the evaluation periods. Overall, nurses and physicians canceled statistically identical percentages of alerted RBC (10.9% vs. 11.5%; p = 0.78) and plasma (21.3% vs. 18.7%; p = 0.22) orders. ConclusionsImplementing a simple evidence-based transfusion alert system at the time of order entry decreased non-evidence based transfusion orders by both nurse and physician providers.

Variation in pediatric outpatient adenotonsillectomy costs in a multihospital network

Identify hospital costs for same-day pediatric adenotonsillectomy (T&A) surgery, and evaluate surgeon, hospital, and patient factors influencing variation in costs, and compare relationship of costs to complications for T&A. Observational retrospective cohort study. A multihospital network's standardized activity-based accounting system was used to determine hospital costs per T&A from 1998 to 2012. Children 1 to 18 years old who underwent same-day T&A surgery were included. Subjects with additional procedures were excluded. Mixed effects analyses were performed to identify variation in mean costs due to surgeon, hospital, and patient factors. Surgeons' mean cost/case was related to subsequent complications, defined as any unplanned visit within 21 days in the healthcare system. The study cohort included 26,626 T&As performed by 66 surgeons at 18 hospitals. Mean cost per T&A was $1,355 ± $505. Mixed effects analysis using patient factors as fixed effects and surgeon and hospital as a random effect identified significant variation in mean costs per surgeon, with 95% of surgeons having a mean cost/case between 67% and 150% of the overall mean (range, $874-$2,232/case). Similar variability was found among hospitals, with 95% of the facilities having mean costs between 64% to 156% of the mean (range, $1,029-$2,385/case). Severity of illness and several other patient factors exhibited small but statistically significant associations with cost. Surgeons' mean cost/case was moderately associated with an increased complication rate. Significant variation in same-day pediatric T&A surgery costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste. 4.

Consolidated clinical microbiology laboratories.

The manner in which medical care is reimbursed in the United States has resulted in significant consolidation in the U.S. health care system. One of the consequences of this has been the development of centralized clinical microbiology laboratories that provide services to patients receiving care in multiple off-site, often remote, locations. Microbiology specimens are unique among clinical specimens in that optimal analysis may require the maintenance of viable organisms. Centralized laboratories may be located hours from patient care settings, and transport conditions need to be such that organism viability can be maintained under a variety of transport conditions. Further, since the provision of rapid results has been shown to enhance patient care, effective and timely means for generating and then reporting the results of clinical microbiology analyses must be in place. In addition, today, increasing numbers of patients are found to have infection caused by pathogens that were either very uncommon in the past or even completely unrecognized. As a result, infectious disease specialists, in particular, are more dependent than ever on access to high-quality diagnostic information from clinical microbiology laboratories. In this point-counterpoint discussion, Robert Sautter, who directs a Charlotte, NC, clinical microbiology laboratory that provides services for a 40-hospital system spread over 3 states in the southeastern United States explains how an integrated clinical microbiology laboratory service has been established in a multihospital system. Richard (Tom) Thomson of the NorthShore University HealthSystem in Evanston, IL, discusses some of the problems and pitfalls associated with large-scale laboratory consolidation.

Making Sense of Patient Safety Event Data

Over the past two decades, the focus on capturing and understanding patient safety events has led to the development of several initiatives and programs in hospitals across the country to increase the reporting of these events. Computerized reporting systems are an integral part of these programs. With these systems going live, hospitals now have databases that contain large numbers of patient safety event reports. Now, the challenge is to make sense of and effectively analyze the data by examining trends and predicting future events. The purpose of this practice-orientated paper is to describe and demonstrate how to apply advances in information visualization techniques and methods to patient safety event data with the goal of making these data more understandable and actionable. We will discuss the process of how we developed patient safety event visualizations for a multi-hospital healthcare system and provide visualization techniques, resources, guidelines, and practical examples.

Towards the Development of a Resilience Engineering Tool to Improve Patient Safety

Over the last few years, patient safety research has seen a paradigm-shift marked by the advent of Resilience Engineering (RE). Findings from the team’s previous research on the efficacy of root-cause analysis in improving patient safety revealed the potential to analyze existing resilient system properties and leverage the same in system-design and improvement. A multi-phase research plan to develop a lessons-learned system for resilience engineering in healthcare is described. The focus of this paper is the first phase, which involved critical-incident interviews to elicit detailed information from frontline health care workers regarding real-life examples of resilience. 14 interviews were conducted with clinicians and nurses from a large, multi-hospital medical system. Multiple examples of resilience and factors pertinent to patient safety were extracted and aligned with system capabilities which are the cornerstones of resilience – learning, responding, anticipating and monitoring. Resilience was also seen to manifest at various levels of the work organization. These results demonstrate the feasibility of using the critical incident interviewing method to analyze resilience in a healthcare organization. The data from the interviews will further be used to develop a Resilience Engineering Tool to Improve Patient Safety (RETIPS) that can be implemented organization-wide for reporting and analysis of resilience-based cases.

CE: Original Research: Staff nurses' use of research to facilitate evidence-based practice.

To determine to what extent RNs in an acute care multihospital system used research findings in their practice; what types of knowledge they used in their practice; and what personal, professional, and organizational factors enhanced or hindered their research utilization. A cross-sectional, descriptive, online survey design was used. The survey, which asked about use of research findings in practice and evidence-based practice (EBP) participation, was placed on the hospital system intranet. Of the 2,900 RNs invited to participate, 1,112 nurses completed usable surveys, for a response rate of 38%. This article reports findings for 794 of the staff nurses who responded to the survey. The forms of knowledge that staff nurses reported relying on most were their personal experience with patients, conferences, hospital policies and procedures, physician colleagues, and nursing peers. Although a variety of resources were available for nurses to use in locating research and implementing EBP, respondents reported many of the same barriers that have been reported in other studies over the last two decades: lack of time, lack of resources, and lack of knowledge. Although their attitudes about research utilization and EBP were positive overall, respondents expected unit-based educators and clinical nurse specialists to collect and synthesize the research for them. These findings are similar to those of other recent studies regarding nurses' research utilization and EBP. A great deal of work remains to be done if we are to inform, educate, and assist staff nurses in using research and implementing EBP. It may be unrealistic to expect bedside nurses to add these activities to their duties unless they are compensated for the time and have the support of master's or doctorally prepared nurses to serve as EBP coaches and champions.

Healthcare strategic management and the resource based view

Purpose– The purpose of this paper is to examine how two large health systems formulate and implement strategy with a specific focus on differences and similarities in the nature of strategic initiatives across systems. The aim is to gain a better understanding of the role of resource dependency theory (RDT) and resource based view (RBV) in healthcare strategic management.Design/methodology/approach– A comparative case study design is used to describe, categorize and compare strategic change initiatives within a children's health and a multi-hospital system located in two competitive metropolitan markets. A total of 61 in-person semi-structured interviews with healthcare administrators were conducted during 2009. Summary statistics and qualitative content analysis were employed to examine strategic initiatives.Findings– The two health systems have as their top initiatives very similar pursuits, thus indicating that both utilize an externally oriented RDT method of strategy formulation. The relevance of the RBV becomes apparent during resource deployment for strategy implementation. The process of healthcare strategic decision-making incorporates RDT and RBV as separate and compatible activities that are sequential.Research limitations/implications– Results from this comparative case study are based on only two health systems. Further, the RBV perspective only takes managerial resources and time into consideration.Practical implications– Given that external resources are likely to become more constrained, it is important that hospitals leverage relevant internal resources, in the identification of competitive advantages and effective execution of strategic initiatives.Originality/value– The author propose a refined healthcare strategic management framework that takes both RDT and RBV into consideration by systematically linking strategy formulation with deployment of resources.

Unique device identifiers for coronary stent postmarket surveillance and research: A report from the Food and Drug Administration Medical Device Epidemiology Network Unique Device Identifier Demonstration

Although electronic product identification in the consumer sector is ubiquitous, unique identification of medical devices is just being implemented in 2014. To evaluate unique device identifiers (UDIs) in health care, the US Food and Drug Administration (FDA) funded the Medical Device Epidemiology Network initiative, including a demonstration of the implementation of coronary stent UDI data in the information systems of a multihospital system (Mercy Health). This report describes the first phase of the demonstration. An expert panel of interventional cardiologists nominated by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions was convened with representatives of industry, health system members of the Healthcare Transformation Group, the American College of Cardiology National Cardiovascular Data Registry, and FDA to articulate concepts needed to best use UDI-associated data. The expert panel identified 3: (1) use cases for UDI-associated data (eg, research), (2) a supplemental data set of clinically relevant attributes (eg, stent dimensions), and (3) governance and administrative principles for the authoritative management of these data. Eighteen use cases were identified, encompassing clinical care, supply chain management, consumer information, research, regulatory, and surveillance domains. In addition to the attributes of the FDA Global Unique Device Identification Database, 9 additional coronary stent-specific attributes were required to address use case requirements. Recommendations regarding governance were elucidated as foundational principles for UDI-associated data management. This process for identifying requisite extensions to support the effective use of UDI-associated data should be generalizable. Implementation of a UDI system for medical devices must anticipate both global and device-specific information.

Physician Engagement: Strategic Considerations among Leaders at a Major Health System

The authors utilize qualitative interviews with 38 health administrators at one large metropolitan, multihospital system to help identify perspectives regarding physician engagement. Here they focus on 1) lessons learned from past physician engagement efforts, 2) strategic considerations concerning the engagement of physicians, and 3) recommendations for future action. The authors conclude that current hospital leaders have learned from the failures of the past based on the identification of success factors critical to physician engagement. However, future success may relate directly to the increased attention to criteria by which the organization assesses the success of such engagement.

Predictors of Stage of Adoption for Colorectal Cancer Screening Among African American Primary Care Patients

Compared with other racial groups, African Americans have the highest colorectal cancer (CRC) incidence and mortality rates coupled with lower screening rates. Our study examined the predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy among African American primary care patients who were nonadherent to published screening guidelines. Baseline data (N = 815) in a randomized clinical trial were analyzed. Participants were categorized into precontemplation, contemplation, and preparation stages for FOBT and colonoscopy. Predictor variables were demographics, clinical variables, CRC health beliefs and knowledge, and social support. Hierarchical modeling was to identify significant predictors of stage of adoption. Older, male, Veterans Affairs participants and those with higher perceived self-efficacy, family/friend encouragement, and a provider recommendation had higher odds of being at a more advanced stage of adoption for FOBT. Patients with a history of cancer and higher perceived barriers had higher odds of being at an earlier stage of adoption for FOBT. Predictors of more advanced stage of adoption for colonoscopy included higher perceived benefits, higher perceived self-efficacy, family/friend encouragement, and a provider recommendation for colonoscopy. Higher income (>30 000 vs <15 000) was predictive of earlier stage of adoption for colonoscopy. Enhancing self-efficacy, encouragement from family and friends, and provider recommendations are important components of interventions to promote CRC screening. Nurses can use knowledge of the characteristics associated with stage of adoption to educate and motivate their African American primary care patients to complete CRC screening tests.

A 7 S Bundle Approach To Preventing Surgical Site Infections

The prevention of surgical site infections (SSI) involves the pre-operative, intra-operative and post-operative period. A 7 step systematic approach was developed in a large multi-hospital system to assist surgical, medical and nursing staff in the prevention of SSIs in surgical settings. The approach uses evidence based practices that have demonstrated a reduction in SSIs and are recommended by national organizations.

Pharmacy Practice Model Initiative: Case Studies in Health-System Pharmacy

In 2008, the American Society of Health-System Pharmacists introduced the Pharmacy Practice Model Initiative (PPMI). The goal of this model is to promote pharmacy leaders, better manage resources, and increase focus on patient-centered and team-based care. Few studies have assessed the model’s implementation. PubMed and CINAHL were searched using keywords “pharmacy practice model,” “organizational,” and the MeSH term, “organizational,” from 2008 to 2013. Of the forty-nine findings (articles and summit highlights), two case studies met the inclusion criteria. The first case study involved the University of Minnesota Medical Center, a multi-campus academic medical center. This facility used technology such as pagers for decentralized technicians, computerized provider order entry, and wireless computers on wheels. The implementation teams worked on clinical and distributive functions allowing for consistency in care and improved employee satisfaction. The second case study involved Providence Health & Services, a multihospital system in Washington State and Montana. These facilities used technology such as automated dispensing cabinets, order-image scanners, and automated telephone trees to route calls. The outcome was a positive economic impact with a return on investment of $709,321. An important finding was the lack of research assessing the implementation of the PPMI. Based on positive findings, it is evident that further research is warranted.

Creating an infrastructure for comparative effectiveness research in emergency medical services.

Emergency medical services (EMS) providers deliver the initial care for millions of people in the United States each year. The Institute of Medicine noted a deficit in research necessary to improve prehospital care, created by the existence of data silos, absence of long-term outcomes, and limited stakeholder engagement in research. This article describes a regional effort to create a high-performing infrastructure in southwestern Pennsylvania addressing these fundamental barriers. Regional EMS records from 33 agencies in January 2011 were linked to hospital-based electronic health records (EHRs) in a single nine-hospital system, with manual review of matches for accuracy. The use of community stakeholder engagement was included to guide scientific inquiry, as well as 2-year follow up for patient-centered outcomes. Local EMS medicine stakeholders emphasized the limits of single-agency EMS research and suggested that studies focus on improving cross-cutting, long-term outcomes. Guided by this input, more than 95% of EMS records (2,675 of 2,800) were linked to hospital-based EHRs. More than 80% of records were linked to 2-year mortality, with more deaths among EMS patients with prehospital hypotension (30.5%) or respiratory distress (19.5%) than chest pain (5.4%) or nonspecific complaints (9.4%). A prehospital comparative effectiveness research infrastructure composed of patient-level EMS data, EHRs at multiple hospitals, long-term outcomes, and community stakeholder perspectives is feasible and may be scalable to larger regions and networks. The lessons learned and barriers identified offer a roadmap to answering community and policy-relevant research questions in prehospital care.

Deploying lean in healthcare: Evaluating information technology effectiveness in U.S. hospital pharmacies

This case study provides a lens of operation research for evaluating the use of technology on medication distribution systems in U.S. hospital and helps better understand how technologies improve the healthcare operational performance in terms of processing time and cost. We analyze two prescribing technologies, namely no carbon required (NCR) and digital scanning technologies to quantify the advantages of the medication ordering, transcribing, and dispensing process in a multi-hospital health system. With comparison between these two technologies, the statistical analysis results show a significant reduction on process times by adopting digital scanning technology. The results indicated a reduction of 54.5% in queue time, 32.4% in order entry time, 76.9% in outgoing delay time, and 67.7% in outgoing transit time with the use of digital scanning technology. We also conducted a cost analysis on each of the two technologies, illustrating that the total cost generated by using digital scanning was as low as 37.31% of that generated by NCR. Lessons learned about how to evaluate IT effectiveness by lean methods are presented for both theoretical and practical perspectives.

Improving Care Transitions From Hospital to Home

A task force at a multihospital health care system partnered with home health agencies to improve gaps during the discharge transition process. A standardized order template for home health nursing and remote telemonitoring was developed to decrease discrepancies in communication between hospital health care providers and home health nurses caring for patients with heart failure. Pilot results showed significantly improved communication with no readmissions, using the order template.

Promoting caring-healing relationships: bringing healing touch to the bedside in a multihospital health system.

New legislative mandates, evaluation metrics, and patient demand have led acute care organizations to expand their patient-centered care model to include the use of complementary therapies. One multihospital health system is offering Healing Touch training to nurses who will provide Healing Touch to self, colleagues, and patients, promoting a caring-healing consciousness.