University Of Michigan Health System Research Articles

Did we learn anything from Humpty Dumpty?*

Critical Care Support Services,; University of Michigan HealthSystem; Ann Arbor, MI The author has not disclosed any potential conflicts of interest. *See also p. 2753.

Did we learn anything from Humpty Dumpty?*

Critical Care Support Services,; University of Michigan HealthSystem; Ann Arbor, MI The author has not disclosed any potential conflicts of interest. *See also p. 2753.

Bacterial Pneumonias during an Influenza Pandemic: How Will We Allocate Antibiotics?

We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.

Implementation of Lean Thinking: One Health System’s Journey

Lean Thinking is a management philosophy derived from the manufacturing industry, where Toyota has long been the gold standard. Health care organizations have started to apply this approach to patient care. After initial experimentation, the University of Michigan Health System (UMHS) has adopted Lean Thinking as its uniform approach to quality improvement and is striving to become a complete Lean organization. In 2005, the senior leadership selected an initial set of projects in areas that traced the patient's journey across different care settings within our health system. Four of the projects were as follows: orthopedic surgery clinic scheduling, radiation oncology therapy, peripherally inserted central catheter (PICC) services, and coordination of care to the outpatient setting. Lean Thinking encourages service providers to focus on value as defined by the customer and the relentless elimination of waste that impedes the flow of value. A series of learning projects were conducted to test whether Lean methods would work at UMHS. The following factors were found to be key to LEAN PROJECT SUCCESS: expert guidance for initial efforts, leadership in the form of clinical champions and senior management support of the improvement work, frontline worker engagement in mapping out "current state" processes, identifying waste and designing an improved "future state," using metrics to develop and track interventions, and defining realistic project scope. As UMHS's experience applying Lean Thinking to our patient care processes has grown, so have support, enthusiasm, and expertise within the organization. UMHS's Lean Thinking system, now known as the Michigan Quality System, has emerged as the core improvement strategy.

Discussion

Ann Arbor, Mich. From the Section of Plastic Surgery, The University of Michigan Medical School. Received for publication March 2, 2009; accepted March 5, 2009. Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or the associated article. Kevin C. Chung, M.D., M.S.; Section of Plastic Surgery; University of Michigan Health System; 2130 Taubman Center, SPC 5340; 1500 E. Medical Center Drive; Ann Arbor, Mich. 48109-5340; [email protected]

Is Faculty Presence during Emergent Tracheal Intubations Justified?

We read with interest the prospective trial by Schmidt et al .1and the accompanying editorial,2which suggest that faculty supervision during emergency endotracheal intubations decreases the rate of airway complications. However, as with any observational study, confounders must be considered.First, several variables suggest that the set of intubations supervised by faculty anesthesiologists may have been slightly less emergent than those accomplished without faculty supervision. The reasons for intubation in the supervised group were more commonly airway protection and “other.” The supervised group was more likely to use neuromuscular blockade to accomplish tracheal intubation. The supervised group performed a higher proportion of intubations in the intensive care unit, a setting in which decompensating patients are more likely to be recognized before complete physiologic deterioration. Moreover, unlike some floor settings, intensive care unit beds are uniformly equipped with functioning suction, oxygen, and devices to deliver positive pressure mask ventilation and staffed by support personnel who are more experienced in identifying, mobilizing and participating in emergent clinical scenarios. Regardless of location, urgent and semiemergent intubations are more likely to allow time to assemble a full complement of personnel and equipment, to optimize patient position, and to consider aspiration prophylaxis, all of which should minimize risk of various complications.Second, as the authors suggest, the presence of a second anesthesia provider, irrespective of the level of training or experience, may facilitate safer tracheal intubation. Based on a multivariate logistic regression analysis of data collected in a prospective multicenter study,3tracheal intubation managed by an anesthesia team (including a junior and a senior provider) as opposed to a single senior provider, was shown to protect against airway complications. Our institution's experience and data support the conclusion that a second anesthesia provider, as opposed to a faculty anesthesiologist, is the process characteristic responsible for improved outcomes. The emergency intubation team at our institution includes a junior (CA-1 or CA-2) and senior anesthesiology resident (CA-3 with at least 24 months of laryngoscopic experience). Typically, a faculty member is present when difficult intubation is anticipated. Preliminary analysis of the electronic medical records for 2,460 emergent intubations over a 4-yr period revealed a 2.3% composite complication rate, with no differences based on faculty presence. Operator-reported complications included aspiration (n = 37), dental injury (n = 4), and esophageal intubation (n = 15). Of note, 8.4% of tracheal intubations were accomplished with the aid of a bougie introducer. The availability of this adjunct or providers' experience in its use was not presented by Schmidt et al . This may be responsible for the rate of frequent esophageal intubation in their studied population.Finally, time of day has been shown to affect survival to discharge after cardiopulmonary arrest.4The data collection sheet used by Schmidt et al ., which was presented in previous work,5includes the date and time of intubation. An analysis to evaluate the effect of nighttime or weekend intubations would be helpful. If nighttime intubations, or weekend intubations, or both, result in more complications, the explanation may be decreased faculty presence, but may also be a result of decreased nursing vigilance delaying the recognition of a need for emergency intubation, increased time from code activation to presence of the anesthesiology team, or circadian biologic factors in both patients and staff attempting the intubation.Faculty presence is the standard of care for intubations in the operating room. Extending this standard to emergency intubations would be desirable if it were to improve patient safety. However, undesirable effects on perioperative patient safety and healthcare costs must also be considered. During nights, weekends, and other periods of limited staffing, emergency intubations may pull on-call faculty away from the operating room or intensive care unit. Dedicated faculty to cover emergent intubations will entail increased on-call commitments and economic costs in many centers. These concerns justify a prospective study in either the intensive care unit or the floor with systematic or even randomized allocation of faculty presence to clarify the contribution of faculty anesthesiologists, urgency, location, time of day, and other confounders on significant patient airway outcomes.*University of Michigan Health System, Ann Arbor, Michigan. jmmhyre@umich.edu

Discussion

Ann Arbor, Mich. From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System. Received for publication January 5, 2009. Disclosure:Neither of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. Kevin C. Chung, M.D., M.S., Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, Mich. 48109-0340, [email protected]

Notes From the 2008 ASA Annual Meeting

FROM OCTOBER 19-22, 2008, ASPAN leaders attended the American Society of Anesthesiologists Annual Meeting in Orlando, Florida. The meeting attracted more than 16,000 members, nonmembers, exhibitors, and guests. Denise O'Brien, MSN, RN, ACNS-BC, CPAN, CAPA, FAAN, is a clinical nurse specialist in the UH Postanesthesia Care Unit, University of Michigan Health System, Ann Arbor, MI

Introduction of computerized provider order entry (CPOE) and time impact in an inpatient hematology/oncology service: Serial time and motion studies

e17507 Background: The impact of CPOE on inpatient hematology/oncology care is not well studied. CPOE has many benefits, but concerns exist about increased time required to enter electronic orders compared to handwritten orders. We hypothesized that CPOE would require more order-related time from caregivers, and reduce the amount of time for direct patient care. Methods: Physician assistants (PAs) enter all patient orders (except those for chemotherapy) and are the dedicated and exclusive care providers on this non-house staff service at the main Hospital of the University of Michigan Health System. We chose the PA service for observation as we could eliminate potential biases introduced by rotating house staff we observed in earlier studies. PAs were directly observed at -1, +3 and +8 months post implementation of a CPOE system (Sunrise Clinical Manager, Eclypsis, Atlanta GA). Dedicated observers used a data entry tool with a modified database (available on the Health IT Tools section at healthit.ahrq.gov) on a tablet computer. For analysis, the 60 individual activities were grouped into 6 major categories, as well as an ordering category. We observed the same three PAs for 82.5 hours pre-CPOE, for 75.0 hours at 3 months post and for 70.5 hours 8 months post. Productive time was all non-personal and non-administrative time. The faculty entered chemotherapy orders and supervised the PAs, but were not studied. Results: Overall time for order-related activities was unchanged during the three observation periods, requiring 10.3, 10.6 and 11.4% of productive time, respectively. Time spent on direct patient care (as a percentage of productive time) was also unchanged once CPOE was implemented (50.7% pre vs. 49.8% and 47.8% post). Conclusions: We could not detect differences in order-entry time by well-trained PAs using standardized order sets before and after CPOE implementation on an inpatient hematology/oncology service. The decision to adopt CPOE should not be based on the hypothesis that there will be less (or more) time spent on order entry tasks. No significant financial relationships to disclose.

Cultural Competency and the Pharmacist

There has been significant growth of populations of ethnic minorities in the United States in recent years, with numbers reaching over 100 million in May 2007. Currently, 1 in 3 US residents may be a minority with a diverse cultural and ethnic background. To ensure that a patient’s medical needs are met, it is important that pharmacists understand and appreciate the potential influence of culture and beliefs on pharmaceutical care. According to the National Center for Cultural Competence, cultural competence requires that organizations (1) have a defined set of values and principles and dem onstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-cul tur ally; (2) have the capacity to va lue diversity, conduct self-assessment, manage the dynamics of difference, acquire and institutionalize cultural knowledge, and adapt to diversity and the cultural contexts of the communities they serve; and (3) incorporate the previously listed requirements into all aspects of policy making, administration, practice, and service delivery and in volve systematically consumers, key stakeholders, and communities. Providing culturally competent care can reduce errors occurring as a result of lack of patient understanding. However, being culturally competent means more than speaking a different language; it also may include awareness about other communication styles (eg, eye contact, body language) and understanding cultural beliefs. If a pa tient’s cultural beliefs are un known, treating illnesses may be difficult because of differences in beliefs and methods of treatment. Pharmacists and other health care pro viders must be aware of pa tients’ cultural beliefs and incorporate those beliefs into their treatment plans to achieve desired treatment outcomes. In an effort to improve cultural competence among health care professionals, several online re sources are available that provide information about cultural competency. The US Department of Health and Human Services Web site (http://www.thinkculturalhealth .org) provides continuing education for health care pro viders, links to recent presentations, and other resources and tools related to cultural competence research for health care professionals. A second Web site offering information re garding cultural competency is provided by the University of Michigan Health System’s Program for Multicultural Health (http://www.med.umich.edu/multi cultural/ccp/culcomp.htm). This site provides information on cultural com petence, facts about specific cultures, and information for different disciplines, as well as re search advocacy and policy information. To prepare future pharmacists for work with our diverse population, pharmacy schools and colleges are striving to incorporate cultural competency into pharmacy curriculum. The Accreditation Council for Pharmacy Education requires that the doctor of pharmacy curriculum “facilitate the development of professional practitioners capable of understanding a culturally diverse society and their role in it as health care providers.” Hospital Pharmacy is interested in any approaches that have been made in your practice regarding programs that facilitate the understanding of cultural diversity as it relates to the promotion of medication counseling and adherence. Your views and experiences are welcome at hospitalpharmacy @drugfacts.com.

Clostridium Difficile Infection in the “Oldest” Old: Clinical Outcomes in Patients Aged 80 and Older

Clostridium difficile infection (CDI) represents a cause of substantial morbidity, particularly for older adults. Although older age is a risk factor for CDI, few studies have specifically focused on clinical outcomes in older adults, particularly the "oldest" old. Retrospective review. University of Michigan Health System. All patients aged 80 and older with a positive cytotoxin assay for C. difficile and a clinical course consistent with CDI during 2006. Clinical data were recorded, including comorbid conditions and treatment regimens, as well as outcomes, including treatment failure, infection relapse, and 90-day mortality. Seventy patients aged 80 and older (mean 84.0+/-4.1) with CDI were identified. Metronidazole was given as initial therapy in 65 (92.8%); 18 of these 65 (27.7%) experienced treatment failure, requiring subsequent use of oral vancomycin. Serious adverse events included three episodes of toxic megacolon, two requiring colectomy. One death was directly attributable to CDI. All-cause mortality was 8.6% at 30 days and 17.1% at 90 days. Higher white blood cell (WBC) counts were independently associated with treatment failure (P=.02) and coronary artery disease with 90-day mortality (P=.02). In older adults with CDI, treatment failure on metronidazole occurred frequently and was associated with higher WBC count. Larger prospective studies are needed to determine risk factors for treatment failure and relapse in order to develop better paradigms for CDI treatment in older adults. Initial therapy with vancomycin may be appropriate for elderly patients, especially those with elevated WBC counts.

Maintaining the enterprisewide continuity and interoperability of patient allergy data

The efforts, results, and challenges of a large tertiary care, academic health care system to standardize and integrate allergy information across clinical information systems are discussed. The University of Michigan Health System and its Information Technology Strategic Advisory Committee recognized the necessity for storing and maintaining allergy information in a single repository; therefore, the clinical data repository (CDR) was named as the central database for coded allergens and reactions for the University of Michigan Hospitals and Health Care Centers (UMHHC) electronic medical record. The Enterprise Allergy Project (EAP) began in June 2005 with the formation of a steering committee that included representatives from clinical departments with order-entry systems. The initial phase of the EAP consisted of several components. One component was a one-time conversion of existing free-text allergy information into coded allergens and reactions. Before the implementation of the EAP, the order-entry system only supported the entry of uncoded allergen and reaction information. An initial process of allergy matching reduced the list of un-coded allergens from 272,519 to 29,500 by using terms that indicated no allergies were present and trimming and modifying free-text strings that closely matched or easily translated to a coded allergen counterpart. Another component of the EAP consisted of the interface and technical build to support allergy information processing between the CDR and University of Michigan (UM)-Carelink. One goal of the EAP was to transfer data bidirectionally, but that goal could not safely be accomplished. Implementing a strategy for enterprise allergy integration at UMHHC has improved the quality of allergy information documented as measured by a significant decrease in the amount of uncoded allergens.

Sleep disorders and gastrointestinal symptoms: chicken, egg or vicious cycle?

Neurogastroenterology & MotilityVolume 21, Issue 2 p. 97-99 Sleep disorders and gastrointestinal symptoms: chicken, egg or vicious cycle? M. Maneerattanaporn, M. Maneerattanaporn Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USASearch for more papers by this authorW. D. Chey, W. D. Chey Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USASearch for more papers by this author M. Maneerattanaporn, M. Maneerattanaporn Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USASearch for more papers by this authorW. D. Chey, W. D. Chey Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USASearch for more papers by this author First published: 22 January 2009 https://doi.org/10.1111/j.1365-2982.2008.01254.xCitations: 14 Professor William D. Chey, MD, GI Physiology Laboratory, University of Michigan Health System, 3912 Taubman Center, SPC 0362, Ann Arbor, MI 48109-0362, USA.Tel: +1 734 936 4775; fax: +1 734 936 7392; e-mail: wchey@umich.edu Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume21, Issue2February 2009Pages 97-99 RelatedInformation

Alcohol Use and Cigarette Smoking as Risk Factors for Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Alcohol use and cigarette smoking are associated with various pancreatic diseases, but it is not known whether they associate with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a retrospective case-control study to determine if these activities increase the risk of PEP. We identified 7638 patients who had undergone ERCP in the University of Michigan Health System and applied exclusion criteria to identify 123 with PEP. We randomly selected 308 age- and sex-stratified controls (2.5-fold case sample); after applying exclusion criteria 248 remained. In a masked fashion, we collected data for alcohol use, cigarette smoking, and 5 internal control variables: suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate/difficult cannulation, 2 or more pancreatic injections, and pancreatic stent placement. The univariate model showed an increased frequency of PEP in current drinkers (P < .001), former drinkers (P < .001), and former smokers (P < .001), as well as patients who were suspected of having SOD (P < .001), had undergone pancreatic sphincterotomy (P < .001), had a moderate/difficult cannulation (P = .001), and/or had 2 or more pancreatic injections (P = .007). The frequency of PEP was reduced in current smokers (P < .001). The multivariate model showed that the only independent significant predictors of PEP were current drinking (odds ratio [OR], 4.70; 95% confidence interval [CI], 2.60-8.50; P < .0001), former cigarette smoking (OR, 3.29; 95% CI, 1.28-8.44; P < .013), suspected SOD (OR, 3.69; 95% CI, 1.94-7.02; P < .001), and pancreatic sphincterotomy (OR, 5.91; 95% CI, 2.04-17.14; P = .001). Current alcohol use and potentially former cigarette smoking are new risk factors for PEP. It is important to consider these variables in designing PEP prevention trials.

University of Michigan: Quality and Safety in an Academic Medical Center

The University of Michigan Health System's vision of the Ideal Patient Care Experience is complemented by idealizations of the faculty and staff and clinical practice experiences.

Obesity and Morbid Obesity are Associated With a Greater Conversion Rate to Open Surgery for Standard but Not Hand Assisted Laparoscopic Radical Nephrectomy

We noted that the impact of obesity on renal laparoscopy may vary with the specific surgical approach. Patients who underwent standard and hand assisted laparoscopic radical nephrectomy at our institution were categorized by body mass index as nonobese--body mass index less than 30, obese--30 to 39.9 and morbidly obese--40 kg/m(2) or greater. We assessed the association of intraoperative and postoperative outcomes with body mass index for standard and hand assisted laparoscopic radical nephrectomy. Of 350 patients who underwent standard (196) or hand assisted (154) laparoscopic radical nephrectomy 36% were obese and 12% were morbidly obese. Patients who underwent hand assisted laparoscopic radical nephrectomy had a greater body mass index, more frequent assignment of American Society of Anesthesiologists score 3 or 4 and larger masses than those who underwent standard laparoscopic radical nephrectomy. Despite this fact conversion to open surgery from hand assisted laparoscopic radical nephrectomy did not occur, while such conversion occurred in the standard laparoscopic radical nephrectomy group in 0.8% of nonobese, 3.0% of obese and 17% of morbidly obese patients (association with body mass index p = 0.003). Operative time, intraoperative and postoperative complications, and hospitalization duration did not vary with body mass index. On multivariate analysis only body mass index and not age, gender, American Society of Anesthesiologists score, prior abdominal surgery or tumor size was associated with an increasing likelihood of conversion to open surgery (p = 0.04), and only in the standard laparoscopic radical nephrectomy group. Although obesity and morbid obesity are associated with more frequent conversion to open surgery during standard laparoscopic radical nephrectomy, such conversion did not occur during hand assisted laparoscopic radical nephrectomy. This advantage of hand assisted laparoscopic radical nephrectomy should be considered when planning laparoscopic radical nephrectomy in obese and morbidly obese patients.

Planning for undergraduate teaching

Medical EducationVolume 35, Issue 2 p. 94-96 Planning for undergraduate teaching First published: 07 July 2008 https://doi.org/10.1111/j.1365-2923.2001.00877.x James O Woolliscroft University of Michigan Health System, 3107 Med Sci I, Ann Arbor, Michigan 48109–0610, USA Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume35, Issue2February 2001Pages 94-96 RelatedInformation

Supply and demand in critical care trials: From where will all the subjects come?*

Critical Care Support Services, Mott Respiratory Care, University of Michigan Health System, Ann Arbor, MI The author has not disclosed any potential conflicts of interest. For information regarding this article, E-mail: [email protected]

Association Between Admission Neutrophil to Lymphocyte Ratio and Outcomes in Patients With Acute Coronary Syndrome

The neutrophil/lymphocyte ratio (NLR) has recently been described as a predictor of mortality in patients who undergo percutaneous coronary intervention. The aim of this study was to investigate the utility of admission NLRs in predicting outcomes in patients with acute coronary syndromes (ACS). A total of 2,833 patients admitted to the University of Michigan Health System with diagnoses of ACS from December 1998 to October 2004 were followed. Patients were divided into tertiles according to NLR. The primary end point was all-cause in-hospital and 6-month mortality. The ACS cohort comprised 564 patients with ST-segment elevation myocardial infarctions and 2,269 patients with non-ST-segment elevation ACS. Patients in tertile 3 had higher in-hospital (8.5% vs 1.8%) and 6-month (11.5% vs 2.5%) mortality compared with those in tertile 1 (p <0.001). After adjusting for Global Registry of Acute Coronary Events risk profile, patients in the highest tertile were at an exaggerated risk for in-hospital (odds ratio 2.04, p = 0.013) and 6-month (odds ratio 3.88, p <0.001) mortality. Admission NLR is an independent predictor of in-hospital and 6-month mortality in patients with ACS. This relatively inexpensive marker of inflammation can aid in the risk stratification and prognosis of patients diagnosed with ACS.

Do the AHRQ Patient Safety Indicators Flag Conditions That Are Present at the Time of Hospital Admission?

The Agency for Healthcare Research and Quality (AHRQ) developed 20 patient safety indicators (PSIs) to identify potentially preventable complications of acute inpatient care based on administrative data. The objective of this patient safety performance study was to assess the impact of cases flagged by each PSI for diagnoses that were actually present on admission on unadjusted PSI rates. The latest AHRQ PSI software, which allows users to produce 14 of the 20 PSIs for adult inpatients both without and with a "present on admission" (PoA) variable, was applied to administrative data for adult patients discharged from the University of Michigan Health System (UMHS) in 2006. The impact of the PoA values on unadjusted PSI rates was evaluated. Because of concerns about the accuracy of PoA values, results were compared with those of a prior analysis at UMHS that was similar but based on a review of medical records. Thirteen PSIs had at least 1 case in the numerator. Rates for all but 1 of the 13 were lower using the PoA values and the reduction was statistically significant for 5 PSIs: decubitus ulcer (P < 0.001), foreign body left in (P = 0.033), selected infections due to medical care (P < 0.001), postoperative physiologic and metabolic derangement (P = 0.039), and postoperative pulmonary embolism or deep vein thrombosis (P < 0.001). Results were consistent with those of the analysis of medical records. Unadjusted PSI rates at UMHS are substantially overstated, because the PSIs do not differentiate preexisting conditions from complications and therefore include false positive cases. Because of these findings and the lack of a broader study of the validity of the indicators, PSIs should not be used to profile hospital performance.