1
|
Mark DG, Huang J, Ballard DW, Kene MV, Sax DR, Chettipally UK, Lin JS, Bouvet SC, Cotton DM, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Reed ME. Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study. J Am Heart Assoc 2021; 10:e022539. [PMID: 34743565 PMCID: PMC8751925 DOI: 10.1161/jaha.121.022539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
Collapse
Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | |
Collapse
|
2
|
Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Ballard DW, Reed ME. Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain. J Am Heart Assoc 2021; 10:e020082. [PMID: 33787290 PMCID: PMC8174350 DOI: 10.1161/jaha.120.020082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as “rule‐out” binary classification strategies, while others use graded‐risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin‐only strategies (fourth‐generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA‐ACS). The primary outcome was 60‐day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all‐cause mortality. There were 13 192 patient encounters included with a 60‐day major adverse cardiac event incidence of 3.7%. RISTRA‐ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03–0.10 and 0.07, 95% CI, 0.04–0.11, respectively) and the greatest net benefit across a range of low‐risk thresholds. RISTRA‐ACS demonstrated the highest discrimination for 60‐day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91–0.94, P<0.0001). Conclusions RISTRA‐ACS and HEART pathway were the optimal rule‐out approaches, while RISTRA‐ACS was the best‐performing graded‐risk approach. RISTRA‐ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
Collapse
Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | |
Collapse
|
3
|
Kea B, Warton EM, Ballard DW, Mark DG, Reed ME, Rauchwerger AS, Offerman SR, Chettipally UK, Ramos PC, Le DD, Glaser DS, Vinson DR. Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study. J Atr Fibrillation 2021; 13:2355. [PMID: 34950330 PMCID: PMC8691349 DOI: 10.4022/jafib.2355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/12/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. METHODS This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. RESULTS Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. DISCUSSION Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.
Collapse
Affiliation(s)
- Bory Kea
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - E Margaret Warton
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Dustin W Ballard
- Kaiser Permanente Northern California Division of Research, Oakland, California
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Mary E Reed
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Steven R Offerman
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, California
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - Daphne D Le
- University of California, Berkeley, California
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, Oakland, California
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Sacramento Medical Center, Sacramento, California
| |
Collapse
|
4
|
Kharbanda AB, Vazquez-Benitez G, Ballard DW, Vinson DR, Chettipally UK, Dehmer SP, Ekstrom H, Rauchwerger AS, McMichael B, Cotton DM, Kene MV, Simon LE, Zhu J, Warton EM, O’Connor PJ, Kharbanda EO. Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial. JAMA Netw Open 2021; 4:e2036344. [PMID: 33560426 PMCID: PMC7873779 DOI: 10.1001/jamanetworkopen.2020.36344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis. OBJECTIVE To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis. DESIGN, SETTING, AND PARTICIPANTS In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019. INTERVENTIONS AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care. MAIN OUTCOMES AND MEASURES Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool. RESULTS We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group. CONCLUSIONS AND RELEVANCE In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02633735.
Collapse
Affiliation(s)
- Anupam B. Kharbanda
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - David R. Vinson
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | | | - Steven P. Dehmer
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Heidi Ekstrom
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Adina S. Rauchwerger
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Brianna McMichael
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | | | - Laura E. Simon
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Jingyi Zhu
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - E. Margaret Warton
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | | | | |
Collapse
|
5
|
Simon LE, Rauchwerger AS, Chettipally UK, Babakhanian L, Vinson DR, Warton EM, Reed ME, Kharbanda AB, Kharbanda EO, Ballard DW. Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment. J Am Med Inform Assoc 2021; 26:1360-1363. [PMID: 31340023 DOI: 10.1093/jamia/ocz118] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 12/25/2022] Open
Abstract
Prospective enrollment of research subjects in the fast-paced emergency department (ED) is challenging. We sought to develop a software application to increase real-time clinical trial enrollment during an ED visit. The Prospective Intelligence System for Clinical Emergency Services (PISCES) scans the electronic health record during ED encounters for preselected clinical characteristics of potentially eligible study participants and notifies the treating physician via mobile phone text alerts. PISCES alerts began 3 months into a cluster randomized trial of an electronic health record-based risk stratification tool for pediatric abdominal pain in 11 Northern California EDs. We compared aggregate enrollment before (2577 eligible patients, October 2016 to December 2016) and after (12 049 eligible patients, January 2017 to January 2018) PISCES implementation. Enrollment increased from 10.8% to 21.1% following PISCES implementations (P < .001). PISCES significantly increased study enrollment and can serve as a valuable tool to assist prospective research enrollment in the ED.
Collapse
Affiliation(s)
- Laura E Simon
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | | | - Uli K Chettipally
- Emergency Department, Kaiser Permanente South San Francisco Medical Center, South San Francisco, California, USA
| | | | - David R Vinson
- Division of Research, Kaiser Permanente, Oakland, California, USA.,Emergency Department, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | | | - Mary E Reed
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Anupam B Kharbanda
- Emergency Department, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Elyse O Kharbanda
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Dustin W Ballard
- Division of Research, Kaiser Permanente, Oakland, California, USA.,Emergency Department, Kaiser Permanente San Rafael Medical Center, San Rafael, California, USA
| |
Collapse
|
6
|
|
7
|
Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Ballard DW, Reed ME. Automated Retrospective Calculation of the EDACS and HEART Scores in a Multicenter Prospective Cohort of Emergency Department Chest Pain Patients. Acad Emerg Med 2020; 27:1028-1038. [PMID: 32596953 DOI: 10.1111/acem.14068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Coronary risk scores are commonly applied to emergency department patients with undifferentiated chest pain. Two prominent risk score-based protocols are the Emergency Department Assessment of Chest pain Score Accelerated Diagnostic Protocol (EDACS-ADP) and the History, ECG, Age, Risk factors, and Troponin (HEART) pathway. Since prospective documentation of these risk determinations can be challenging to obtain, quality improvement projects could benefit from automated retrospective risk score classification methodologies. METHODS EDACS-ADP and HEART pathway data elements were prospectively collected using a Web-based electronic clinical decision support (eCDS) tool over a 24-month period (2018-2019) among patients presenting with chest pain to 13 EDs within an integrated health system. Data elements were also extracted and processed electronically (retrospectively) from the electronic health record (EHR) for the same patients. The primary outcome was agreement between the prospective/eCDS and retrospective/EHR data sets on dichotomous risk protocol classification, as assessed by kappa statistics (ĸ). RESULTS There were 12,110 eligible eCDS uses during the study period, of which 66 and 47% were low-risk encounters by EDACS-ADP and HEART pathway, respectively. Agreement on low-risk status was acceptable for EDACS-ADP (ĸ = 0.73, 95% confidence interval [CI] = 0.72 to 0.75) and HEART pathway (ĸ = 0.69, 95% CI = 0.68 to 0.70) and for the continuous scores (interclass correlation coefficients = 0.87 and 0.84 for EDACS and HEART, respectively). CONCLUSIONS Automated retrospective determination of low risk status by either the EDACS-ADP or the HEART pathway provides acceptable agreement compared to prospective score calculations, providing a feasible risk adjustment option for use in large data set analyses.
Collapse
Affiliation(s)
- Dustin G. Mark
- From the Departments of Emergency Medicine and Critical Care Kaiser Permanente Oakland Medical Center Oakland CA USA
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | - Jie Huang
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | - Mamata V. Kene
- the Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA USA
| | - Dana R. Sax
- the Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA USA
| | - Dale M. Cotton
- the Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center South Sacramento CA USA
| | - James S. Lin
- the Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA USA
| | - Sean C. Bouvet
- the Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA USA
| | - Uli K. Chettipally
- the Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA USA
| | - Megan L. Anderson
- the Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA USA
| | - Ian D. McLachlan
- the Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA USA
| | - Laura E. Simon
- the University of California San Diego School of Medicine San Diego CA USA
| | - Judy Shan
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | | | - David R. Vinson
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
- the Department of Emergency Medicine Kaiser Permanente Sacramento Medical Center Sacramento CA USA
| | - Dustin W. Ballard
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
- and the Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA USA
| | - Mary E. Reed
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | | |
Collapse
|
8
|
Simon LE, Kene MV, Warton EM, Rauchwerger AS, Vinson DR, Reed ME, Chettipally UK, Mark DG, Sax DR, McLachlan DI, Cotton DM, Lin JS, Vazquez-Benitez G, Kharbanda AB, Kharbanda EO, Ballard DW. Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years. Acad Emerg Med 2020; 27:821-831. [PMID: 32239713 PMCID: PMC8310728 DOI: 10.1111/acem.13931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. METHODS This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. RESULTS Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). CONCLUSION Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.
Collapse
Affiliation(s)
- Laura E. Simon
- Division of Research, Kaiser Permanente, Oakland, CA
- University of California San Diego School of Medicine, La Jolla, CA
| | - Mamata V. Kene
- The Permanente Medical Group, Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | | | | | - David R. Vinson
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Mary E. Reed
- Division of Research, Kaiser Permanente, Oakland, CA
| | - Uli K. Chettipally
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dustin G. Mark
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Dana R. Sax
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - D. Ian McLachlan
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dale M. Cotton
- The Permanente Medical Group, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA
| | - James S. Lin
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | | | | | - Dustin W. Ballard
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente San Rafael Medical Center, San Rafael, CA
| |
Collapse
|
9
|
Cotton DM, Vinson DR, Vazquez-Benitez G, Margaret Warton E, Reed ME, Chettipally UK, Kene MV, Lin JS, Mark DG, Sax DR, McLachlan ID, Rauchwerger AS, Simon LE, Kharbanda AB, Kharbanda EO, Ballard DW. Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting. Ann Emerg Med 2019; 74:471-480. [PMID: 31229394 PMCID: PMC8364751 DOI: 10.1016/j.annemergmed.2019.04.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/21/2019] [Accepted: 04/19/2019] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS). METHODS We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC. RESULTS We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS. CONCLUSION The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.
Collapse
Affiliation(s)
- Dale M Cotton
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, South Sacramento Medical Center, Sacramento, CA.
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, Sacramento Medical Center, Sacramento, CA
| | | | | | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, CA
| | - Uli K Chettipally
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, South San Francisco Medical Center, South San Francisco, CA
| | - Mamata V Kene
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, San Leandro Medical Center, San Leandro, CA
| | - James S Lin
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Santa Clara Medical Center, Santa Clara, CA
| | - Dustin G Mark
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, Oakland Medical Center, Oakland, CA
| | - Dana R Sax
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Oakland Medical Center, Oakland, CA
| | - Ian D McLachlan
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, San Francisco Medical Center, San Francisco, CA
| | | | - Laura E Simon
- Kaiser Permanente, Division of Research, Oakland, CA
| | - Anupam B Kharbanda
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, MN
| | | | - Dustin W Ballard
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, San Rafael Medical Center, San Rafael, CA
| |
Collapse
|
10
|
Ballard DW, Kuppermann N, Vinson DR, Tham E, Hoffman JM, Swietlik M, Deakyne Davies SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Richards R, Casper TC, Goldberg HS, Grundmeier RW, Dayan PS. Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries. Ann Emerg Med 2019; 73:440-451. [DOI: 10.1016/j.annemergmed.2018.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 11/26/2022]
|
11
|
Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, Pleshakov TS, McLachlan ID, Yamin CK, Elms AR, Iskin HR, Vemula R, Yealy DM, Ballard DW. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med 2018; 169:855-865. [PMID: 30422263 DOI: 10.7326/m18-1206] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. OBJECTIVE To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. DESIGN Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). SETTING All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). PATIENTS Adult ED patients with acute PE. INTERVENTION Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. MEASUREMENTS The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. RESULTS Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. LIMITATION Lack of random allocation. CONCLUSION Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. PRIMARY FUNDING SOURCE Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.
Collapse
Affiliation(s)
- David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente Sacramento Medical Center, Sacramento, California (D.R.V.)
| | - Dustin G Mark
- The Permanente Medical Group, Kaiser Permanente Northern California, and Kaiser Permanente Oakland Medical Center, Oakland, California (D.G.M.)
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, and Kaiser Permanente South San Francisco Medical Center, South San Francisco, California (U.K.C.)
| | - Jie Huang
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Mary E Reed
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - James S Lin
- The Permanente Medical Group, Oakland, and Kaiser Permanente Santa Clara Medical Center, Sacramento, California (J.S.L.)
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Leandro Medical Center, Sacramento, California (M.V.K.)
| | | | - Dana R Sax
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Tamara S Pleshakov
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.S.P.)
| | - Ian D McLachlan
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Francisco Medical Center, San Francisco, California (I.D.M.)
| | - Cyrus K Yamin
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Andrew R Elms
- The Permanente Medical Group, Oakland, and Kaiser Permanente South Sacramento Medical Center, Sacramento, California (A.R.E.)
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan (H.R.I.)
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio (R.V.)
| | - Donald M Yealy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y.)
| | - Dustin W Ballard
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente San Rafael Medical Center, San Rafael, California (D.W.B.)
| | | |
Collapse
|
12
|
Kharbanda AB, Vazquez-Benitez G, Ballard DW, Vinson DR, Chettipally UK, Kene MV, Dehmer SP, Bachur RG, Dayan PS, Kuppermann N, O’Connor PJ, Kharbanda EO. Development and Validation of a Novel Pediatric Appendicitis Risk Calculator (pARC). Pediatrics 2018; 141:e20172699. [PMID: 29535251 PMCID: PMC5869337 DOI: 10.1542/peds.2017-2699] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We sought to develop and validate a clinical calculator that can be used to quantify risk for appendicitis on a continuous scale for patients with acute abdominal pain. METHODS The pediatric appendicitis risk calculator (pARC) was developed and validated through secondary analyses of 3 distinct cohorts. The derivation sample included visits to 9 pediatric emergency departments between March 2009 and April 2010. The validation sample included visits to a single pediatric emergency department from 2003 to 2004 and 2013 to 2015. Variables evaluated were as follows: age, sex, temperature, nausea and/or vomiting, pain duration, pain location, pain with walking, pain migration, guarding, white blood cell count, and absolute neutrophil count. We used stepwise regression to develop and select the best model. Test performance of the pARC was compared with the Pediatric Appendicitis Score (PAS). RESULTS The derivation sample included 2423 children, 40% of whom had appendicitis. The validation sample included 1426 children, 35% of whom had appendicitis. The final pARC model included the following variables: sex, age, duration of pain, guarding, pain migration, maximal tenderness in the right-lower quadrant, and absolute neutrophil count. In the validation sample, the pARC exhibited near perfect calibration and a high degree of discrimination (area under the curve: 0.85; 95% confidence interval: 0.83 to 0.87) and outperformed the PAS (area under the curve: 0.77; 95% confidence interval: 0.75 to 0.80). By using the pARC, almost half of patients in the validation cohort could be accurately classified as at <15% risk or ≥85% risk for appendicitis, whereas only 23% would be identified as having a comparable PAS of <3 or >8. CONCLUSIONS In our validation cohort of patients with acute abdominal pain, the pARC accurately quantified risk for appendicitis.
Collapse
Affiliation(s)
- Anupam B. Kharbanda
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota
| | | | - Dustin W. Ballard
- The Permanente Medical Group, Inc and Division of Research, Kaiser Permanente, Oakland, California
| | - David R. Vinson
- The Permanente Medical Group, Inc and Division of Research, Kaiser Permanente, Oakland, California
| | - Uli K. Chettipally
- The Permanente Medical Group, Inc and Division of Research, Kaiser Permanente, Oakland, California
| | - Mamata V. Kene
- The Permanente Medical Group, Inc and Division of Research, Kaiser Permanente, Oakland, California
| | - Steven P. Dehmer
- Division of Research, HealthPartners Institute, Bloomington, Minnesota
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Peter S. Dayan
- Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; and
| | - Nathan Kuppermann
- Emergency Medicine and Pediatrics, University of California Davis Health, Sacramento, California
| | | | | |
Collapse
|
13
|
Vinson DR, Warton EM, Mark DG, Ballard DW, Reed ME, Chettipally UK, Singh N, Bouvet SZ, Kea B, Ramos PC, Glaser DS, Go AS. Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department. West J Emerg Med 2018; 19:346-360. [PMID: 29560065 PMCID: PMC5851510 DOI: 10.5811/westjem.2017.9.35671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). Methods This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Results Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Conclusion Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.
Collapse
Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | | | - Dustin G Mark
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Oakland Medical Center, Department of Emergency Medicine, Oakland, California
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente San Rafael Medical Center, Department of Emergency Medicine, San Rafael, California
| | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente South San Francisco Medical Center, Department of Emergency Medicine, San Francisco, California
| | - Nimmie Singh
- Mercy Redding Family Practice Residency Program, Redding, California
| | - Sean Z Bouvet
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente Walnut Creek Medical Center, Department of Emergency Medicine, Walnut Creek, California
| | - Bory Kea
- Oregon Health and Science University, Department of Emergency Medicine, Portland, Oregon
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - Alan S Go
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,University of California, San Francisco, Departments of Epidemiology, Biostatistics, and Medicine, San Francisco, California.,Stanford University School of Medicine, Department of Health Research and Policy, Palo Alto, California
| |
Collapse
|
14
|
Dayan PS, Ballard DW, Tham E, Hoffman JM, Swietlik M, Deakyne SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Vinson DR, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Wang J, Casper TC, Goldberg HS, Grundmeier RW, Kuppermann N. Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support. Pediatrics 2017; 139:peds.2016-2709. [PMID: 28341799 DOI: 10.1542/peds.2016-2709] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma. METHODS Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend. RESULTS We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P < .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%). CONCLUSIONS The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.
Collapse
Affiliation(s)
- Peter S Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York;
| | - Dustin W Ballard
- Kaiser Permanente, San Rafael Medical Center, San Rafael, California.,Division of Research, Kaiser Permanente, Oakland, California
| | - Eric Tham
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | | | - Marguerite Swietlik
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Sara J Deakyne
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Evaline A Alessandrini
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leah Tzimenatos
- Departments of Emergency Medicine and.,Pediatrics, University of California Davis School of Medicine, Sacramento, California
| | - Lalit Bajaj
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - David R Vinson
- Division of Research, Kaiser Permanente, Oakland, California.,Kaiser Permanente, Roseville Medical Center, Roseville, California
| | - Dustin G Mark
- Kaiser Permanente, Oakland Medical Center, Oakland, California
| | - Steve R Offerman
- Kaiser Permanente, South Sacramento Medical Center, Sacramento, California,
| | - Uli K Chettipally
- Kaiser Permanente, South San Francisco Medical Center, San Francisco, California
| | - Marilyn D Paterno
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Molly H Schaeffer
- Information Systems, Partners HealthCare System, Boston, Massachusetts
| | - Jun Wang
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Howard S Goldberg
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Information Systems, Partners HealthCare System, Boston, Massachusetts
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, University of California Davis School of Medicine, Sacramento, California
| | | | | | | |
Collapse
|
15
|
Vinson DR, Ballard DW, Mark DG, Chettipally UK. Shared decision making in low risk chest pain: looking ahead. BMJ 2017; 356:j324. [PMID: 28115318 DOI: 10.1136/bmj.j324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | | | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA 94612, USA
| | | |
Collapse
|
16
|
Calvert JS, Price DA, Barton CW, Chettipally UK, Das R. Discharge recommendation based on a novel technique of homeostatic analysis. J Am Med Inform Assoc 2017; 24:24-29. [PMID: 27026611 PMCID: PMC7654071 DOI: 10.1093/jamia/ocw014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 12/30/2015] [Accepted: 01/21/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We propose a computational framework for integrating diverse patient measurements into an aggregate health score and applying it to patient stability prediction. MATERIALS AND METHODS We mapped retrospective patient data from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) II clinical database into a discrete multidimensional space, which was searched for measurement combinations and trends relevant to patient outcomes of interest. Patient trajectories through this space were then used to make outcome predictions. As a case study, we built AutoTriage, a patient stability prediction tool to be used for discharge recommendation. RESULTS AutoTriage correctly identified 3 times as many stabilizing patients as existing tools and achieved an accuracy of 92.9% (95% CI: 91.6-93.9%), while maintaining 94.5% specificity. Analysis of AutoTriage parameters revealed that interdependencies between risk factors comprised the majority of each patient stability score. DISCUSSION AutoTriage demonstrated an improvement in the sensitivity of existing stability prediction tools, while considering patient safety upon discharge. The relative contributions of risk factors indicated that time-series trends and measurement interdependencies are most important to stability prediction. CONCLUSION Our results motivate the application of multidimensional analysis to other clinical problems and highlight the importance of risk factor trends and interdependencies in outcome prediction.
Collapse
Affiliation(s)
| | | | - Christopher W Barton
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Uli K Chettipally
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
| | | |
Collapse
|
17
|
Ballard DW, Vemula R, Chettipally UK, Kene MV, Mark DG, Elms AK, Lin JS, Reed ME, Huang J, Rauchwerger AS, Vinson DR. Optimizing Clinical Decision Support in the Electronic Health Record. Clinical Characteristics Associated with the Use of a Decision Tool for Disposition of ED Patients with Pulmonary Embolism. Appl Clin Inform 2016; 7:883-98. [PMID: 27652375 DOI: 10.4338/aci-2016-05-ra-0073] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/17/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Adoption of clinical decision support (CDS) tools by clinicians is often limited by workflow barriers. We sought to assess characteristics associated with clinician use of an electronic health record-embedded clinical decision support system (CDSS). METHODS In a prospective study on emergency department (ED) activation of a CDSS tool across 14 hospitals between 9/1/14 to 4/30/15, the CDSS was deployed at 10 active sites with an on-site champion, education sessions, iterative feedback, and up to 3 gift cards/clinician as an incentive. The tool was also deployed at 4 passive sites that received only an introductory educational session. Activation of the CDSS - which calculated the Pulmonary Embolism Severity Index (PESI) score and provided guidance - and associated clinical data were collected prospectively. We used multivariable logistic regression with random effects at provider/facility levels to assess the association between activation of the CDSS tool and characteristics at: 1) patient level (PESI score), 2) provider level (demographics and clinical load at time of activation opportunity), and 3) facility level (active vs. passive site, facility ED volume, and ED acuity at time of activation opportunity). RESULTS Out of 662 eligible patient encounters, the CDSS was activated in 55%: active sites: 68% (346/512); passive sites 13% (20/150). In bivariate analysis, active sites had an increase in activation rates based on the number of prior gift cards the physician had received (96% if 3 prior cards versus 60% if 0, p<0.0001). At passive sites, physicians < age 40 had higher rates of activation (p=0.03). In multivariable analysis, active site status, low ED volume at the time of diagnosis and PESI scores I or II (compared to III or higher) were associated with higher likelihood of CDSS activation. CONCLUSIONS Performing on-site tool promotion significantly increased odds of CDSS activation. Optimizing CDSS adoption requires active education.
Collapse
Affiliation(s)
- Dustin W Ballard
- Dustin W. Ballard, 1600 Los Gamos Drive, Suite 220, San Rafael, CA 94903,
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Calvert JS, Price DA, Chettipally UK, Barton CW, Feldman MD, Hoffman JL, Jay M, Das R. A computational approach to early sepsis detection. Comput Biol Med 2016; 74:69-73. [DOI: 10.1016/j.compbiomed.2016.05.003] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/15/2016] [Accepted: 05/08/2016] [Indexed: 12/14/2022]
|
19
|
Ballard DW, Reed ME, Singh N, Rauchwerger AS, Hamity CA, Warton EM, Chettipally UK, Mark DG, Vinson DR. Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit. Ann Emerg Med 2015; 66:646-654.e2. [DOI: 10.1016/j.annemergmed.2015.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 03/14/2015] [Accepted: 04/06/2015] [Indexed: 11/29/2022]
|
20
|
Ballard DW, Kim AS, Huang J, Park DK, Kene MV, Chettipally UK, Iskin HR, Hsu J, Vinson DR, Mark DG, Reed ME. Implementation of Computerized Physician Order Entry Is Associated With Increased Thrombolytic Administration for Emergency Department Patients With Acute Ischemic Stroke. Ann Emerg Med 2015; 66:601-10. [PMID: 26362574 PMCID: PMC5111545 DOI: 10.1016/j.annemergmed.2015.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/16/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke. METHODS We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center. RESULTS Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality. CONCLUSION For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.
Collapse
Affiliation(s)
- Dustin W Ballard
- Kaiser Permanente San Rafael Medical Center, San Rafael, CA; Kaiser Permanente Division of Research, Oakland, CA.
| | - Anthony S Kim
- Department of Neurology, University of California at San Francisco, San Francisco, CA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA
| | - David K Park
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | - Mamata V Kene
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | - Uli K Chettipally
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA
| | | | - John Hsu
- Mongan Institute for Health Policy, Massachusetts General Hospital, Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Dustin G Mark
- Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA
| |
Collapse
|
21
|
Ballard DW, Reed ME, Rauchwerger AS, Chettipally UK, Offerman SR, Mark DG, Vinson DR. Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study. Acad Emerg Med 2014; 21:623-30. [PMID: 25039545 DOI: 10.1111/acem.12386] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/12/2013] [Accepted: 01/02/2014] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. METHODS The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. RESULTS The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters. CONCLUSIONS In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.
Collapse
Affiliation(s)
- Dustin W. Ballard
- The Permanente Medical Group; Oakland CA
- The Department of Emergency Medicine; Kaiser Permanente, San Rafael Medical Center; San Rafael CA
| | - Mary E. Reed
- The Kaiser Permanente Division of Research; Oakland CA
| | | | - Uli K. Chettipally
- The Permanente Medical Group; Oakland CA
- The Department of Emergency Medicine; South San Francisco Medical Center; San Francisco CA
| | - Steven R. Offerman
- The Permanente Medical Group; Oakland CA
- The Department of Emergency Medicine; South Sacramento Medical Center; Sacramento CA
| | - Dustin G. Mark
- The Permanente Medical Group; Oakland CA
- The Department of Emergency Medicine; Oakland Medical Center; Oakland CA
| | - David R. Vinson
- The Permanente Medical Group; Oakland CA
- The Department of Emergency Medicine; Roseville Medical Centers; Roseville CA
| | | |
Collapse
|
22
|
Vinson DR, Ballard DW, Stevenson MD, Mark DG, Reed ME, Rauchwerger AS, Chettipally UK, Offerman SR. Predictors of unattempted central venous catheterization in septic patients eligible for early goal-directed therapy. West J Emerg Med 2014; 15:67-75. [PMID: 24578768 PMCID: PMC3935788 DOI: 10.5811/westjem.2013.8.15809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 07/08/2013] [Accepted: 08/13/2013] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or the presence of relative contraindications on undertaking central line placement in septic emergency department (ED) patients eligible for early goal-directed therapy (EGDT) have not been well described. We sought to determine the association of relative normotension (sustained systolic blood pressure >90 mmHg independent of or in response to an initial crystalloid resuscitation of 20 mL/kg), obesity (body mass index [BMI] ≥30), moderate thrombocytopenia (platelet count <50,000 per μL), and coagulopathy (international normalized ratio ≥2.0) with unattempted CVC in EGDT-eligible patients. METHODS This was a retrospective cohort study of 421 adults who met EGDT criteria in 5 community EDs over a period of 13 months. We compared patients with attempted thoracic (internal jugular or subclavian) CVC with those who did not undergo an attempted thoracic line. We also compared patients with any attempted CVC (either thoracic or femoral) with those who did not undergo any attempted central line. We used multivariate logistic regression analysis to calculate adjusted odd ratios (AORs). RESULTS In our study, 364 (86.5%) patients underwent attempted thoracic CVC and 57 (13.5%) did not. Relative normotension was significantly associated with unattempted thoracic CVC (AOR 2.6 95% confidence interval [CI], 1.6-4.3), as were moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5-10.1) and coagulopathy (AOR 2.7; 95% CI, 1.3-5.6). When assessing for attempted catheterization of any central venous site (thoracic or femoral), 382 (90.7%) patients underwent attempted catheterization and 39 (9.3%) patients did not. Relative normotension (AOR 2.3; 95% CI, 1.2-4.5) and moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5-10.3) were significantly associated with unattempted CVC, whereas coagulopathy was not (AOR 0.6; 95% CI, 0.2-1.8). Obesity was not significantly associated with unattempted CVC, either thoracic in location or at any site. CONCLUSION Septic patients eligible for EGDT with relative normotension and those with moderate thrombocytopenia were less likely to undergo attempted CVC at any site. Those with coagulopathy were also less likely to undergo attempted thoracic central line placement. Knowledge of the decision-making calculus at play for physicians considering central venous catheterization in this population can help inform physician education and performance improvement programs.
Collapse
Affiliation(s)
- David R. Vinson
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Roseville Medical Center, Roseville, California
| | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | | | - Dustin G. Mark
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Mary E. Reed
- Kaiser Permanente Division of Research, Oakland, California
| | | | - Uli K. Chettipally
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, California
| | - Steven R. Offerman
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| |
Collapse
|
23
|
Offerman SR, Rauchwerger AS, Nishijima DK, Ballard DW, Chettipally UK, Vinson DR, Reed ME, Holmes JF. Use of an electronic medical record "dotphrase" data template for a prospective head injury study. West J Emerg Med 2013; 14:109-13. [PMID: 23599842 PMCID: PMC3628454 DOI: 10.5811/westjem.2012.11.13400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 11/19/2012] [Indexed: 11/11/2022] Open
Abstract
Introduction: The adoption of electronic medical records (EMRs) in emergency departments (EDs) has changed the way that healthcare information is collected, charted, and stored. A challenge for researchers is to determine how EMRs may be leveraged to facilitate study data collection efforts. Our objective is to describe the use of a unique data collection system leveraging EMR technology and to compare data entry error rates to traditional paper data collection. Methods: This was a retrospective review of data collection methods during a multicenter study of ED, anti-coagulated, head injury patients. On-shift physicians at 4 centers enrolled patients and prospectively completed data forms. These physicians had the option of completing a paper data form or an electronic “dotphrase” (DP) data form. A feature of our Epic®-based EMR is the ability to use DPs to assist in medical information entry. A DP is a preset template that may be inserted into the EMR when the physician types a period followed by a code phrase (in this case “.ichstudy”). Once the study DP was inserted at the bottom of the electronic ED note, it prompted enrolling physicians to answer study questions. Investigators then extracted data directly from the EMR. Results: From July 2009 through December 2010, we enrolled 883 patients. DP data forms were used in 288 (32.6%; 95% confidence interval [CI] 29.5, 35.7%) cases and paper data forms in 595 (67.4%; 95% CI 64.3, 70.5%). Sixty-six (43.7%; 95% CI 35.8, 51.6%) of 151 physicians enrolling patients used DP data entry at least once. Using multivariate analysis, we found no association between physician age, gender, or tenure and DP use. Data entry errors were more likely on paper forms (234/595, 39.3%; 95% CI 35.4, 43.3%) than DP forms (19/288, 6.6%; 95% CI 3.7, 9.5%), difference in error rates 32.7% (95% CI 27.9, 37.6%, P < 0.001). Conclusion: DP data collection is a feasible means of data collection. DP data forms maintain all study data within the secure EMR environment, obviating the need to maintain and collect paper data forms. This innovation was embraced by many of our emergency physicians and resulted in lower data entry error rates.
Collapse
Affiliation(s)
- Steven R Offerman
- Kaiser Permanente South Sacramento, Department of Emergency Medicine, Sacramento, California
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Ballard DW, Rauchwerger AS, Reed ME, Vinson DR, Mark DG, Offerman SR, Chettipally UK, Graetz I, Dayan P, Kuppermann N. Emergency physicians' knowledge and attitudes of clinical decision support in the electronic health record: a survey-based study. Acad Emerg Med 2013; 20:352-60. [PMID: 23701342 DOI: 10.1111/acem.12109] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Revised: 09/24/2012] [Accepted: 10/26/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to investigate clinician knowledge of and attitudes toward clinical decision support (CDS) and its incorporation into the electronic health record (EHR). METHODS This was an electronic survey of emergency physicians (EPs) within an integrated health care delivery system that uses a complete EHR. Randomly assigned respondents completed one of two questionnaires, both including a hypothetical vignette and self-reported knowledge of and attitudes about CDS. One vignette version included CDS, and the other did not (NCDS). The vignette described a scenario in which a cranial computed tomography (CCT) is not recommended by validated prediction rules (the Pediatric Emergency Care Applied Research Network [PECARN] rules). In both survey versions, subjects responded first with their likely approach to evaluation and then again after receiving either CDS (the PECARN prediction rules) or no additional support. Descriptive statistics were used for self-reported responses and multivariate logistic regression was used to identify predictors of self-reported knowledge and use of the PECARN rules, as well as use of vignette responses. RESULTS There were 339 respondents (68% response rate), with 172 of 339 (51%) randomized to the CDS version. Initially, 25% of respondents to each version indicated they would order CCTs. After CDS, 30 of 43 (70%) of respondents who initially would order CCTs changed their management decisions to no CCT versus two of 41 (5%) with the NCDS version (chi-square, p = 0.003). In response to self-report questions, 81 of 338 respondents (24%) reported having never heard of the PECARN prediction rules, 122 of 338 (36%) were aware of the rules but not their specifics, and 135 of 338 (40%) reported knowing the rules and their specifics. Respondents agreed with favorable statements about CDS (75% to 96% agreement across seven statements) and approaches to its implementation into the EHR (60% to 93% agreement across seven statements). In multivariable analyses, EPs with tenure of 5 to 14 years (odds ratio [AOR] = 0.51, 95% confidence interval [CI] = 0.30 to 0.86) and for 15 years or more (AOR = 0.37, 95% CI = 0.20 to 0.70) were significantly less likely to report knowing the specifics of the PECARN prediction rules compared with EPs who practiced for fewer than 5 years. In addition, in the initial vignette responses (across both versions), physicians with ≥15 years of ED tenure compared to those with fewer than 5 years of experience (AOR = 0.30, 95% CI = 0.13 to 0.69), and those reporting knowing the specifics of the PECARN prediction rules were less likely to order CCTs (AOR = 0.53, 95% CI = 0.30 to 0.92). CONCLUSIONS EPs incorporated pediatric head trauma CDS via the EHR into their clinical judgment in a hypothetical scenario and reported favorable opinions of CDS in general and their inclusion into the EHR.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Peter Dayan
- The Division of Pediatric Emergency Medicine; Columbia University; New York; NY
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics; UC Davis; Sacramento; CA
| | | |
Collapse
|
25
|
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med 2013; 20:140-5. [PMID: 23406072 DOI: 10.1111/acem.12074] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 08/13/2012] [Accepted: 08/13/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Appropriate use of cranial computed tomography (CT) scanning in patients with mild blunt head trauma and preinjury anticoagulant or antiplatelet use is unknown. The objectives of this study were: 1) to identify risk factors for immediate traumatic intracranial hemorrhage (tICH) in patients with mild head trauma and preinjury warfarin or clopidogrel use and 2) to derive a clinical prediction rule to identify patients at low risk for immediate tICH. METHODS This was a prospective, observational study at two trauma centers and four community hospitals that enrolled adult emergency department (ED) patients with mild blunt head trauma (initial ED Glasgow Coma Scale [GCS] score 13 to 15) and preinjury warfarin or clopidogrel use. The primary outcome measure was immediate tICH, defined as the presence of ICH or contusion on the initial cranial CT. Risk for immediate tICH was analyzed in 11 independent predictor variables. Clinical prediction rules were derived with both binary recursive partitioning and multivariable logistic regression. RESULTS A total of 982 patients with a mean (± standard deviation [SD]) age of 75.4 (±12.6) years were included in the analysis. Sixty patients (6.1%; 95% confidence interval [CI] = 4.7% to 7.8%) had immediate tICH. History of vomiting (relative risk [RR] = 3.53; 95% CI = 1.80 to 6.94), abnormal mental status (RR = 2.85; 95% CI = 1.65 to 4.92), clopidogrel use (RR = 2.52; 95% CI = 1.55 to 4.10), and headache (RR = 1.81; 95% CI = 1.11 to 2.96) were associated with an increased risk for immediate tICH. Both binary recursive partitioning and multivariable logistic regression were unable to derive a clinical prediction model that identified a subset of patients at low risk for immediate tICH. CONCLUSIONS While several risk factors for immediate tICH were identified, the authors were unable to identify a subset of patients with mild head trauma and preinjury warfarin or clopidogrel use who are at low risk for immediate tICH. Thus, the recommendation is for urgent and liberal cranial CT imaging in this patient population, even in the absence of clinical findings.
Collapse
Affiliation(s)
- Daniel K. Nishijima
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento; CA
| | | | - Dustin W. Ballard
- Kaiser Permanente San Rafael Medical Center and Medical Offices; San Rafael; CA
| | - David R. Vinson
- Kaiser Permanente Sacramento Medical Center and Medical Offices; Sacramento; CA
| | - Uli K. Chettipally
- Kaiser Permanente South San Francisco Medical Center and Medical Offices; San Francisco; CA
| | | | - Mary E. Reed
- Kaiser Permanente Division of Research; Oakland; CA
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento; CA
| | | |
Collapse
|
26
|
Nishijima DK, Holmes JF, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME. In reply. Ann Emerg Med 2013; 61:126-7. [DOI: 10.1016/j.annemergmed.2012.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 08/09/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022]
|
27
|
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012; 59:460-8.e1-7. [PMID: 22626015 DOI: 10.1016/j.annemergmed.2012.04.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 03/23/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage in these patients, however, are unknown. The objective of this study is to address these gaps in knowledge. METHODS A prospective, observational study at 2 trauma centers and 4 community hospitals enrolled emergency department (ED) patients with blunt head trauma and preinjury warfarin or clopidogrel use from April 2009 through January 2011. Patients were followed for 2 weeks. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage were calculated from patients who received initial cranial computed tomography (CT) in the ED. Delayed traumatic intracranial hemorrhage was defined as traumatic intracranial hemorrhage within 2 weeks after an initially normal CT scan result and in the absence of repeated head trauma. RESULTS A total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%) from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics, although concomitant aspirin use was more prevalent among patients receiving clopidogrel. The prevalence of immediate traumatic intracranial hemorrhage was higher in patients receiving clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients receiving clopidogrel. CONCLUSION Although there may be unmeasured confounders that limit intergroup comparison, patients receiving clopidogrel have a significantly higher prevalence of immediate traumatic intracranial hemorrhage compared with patients receiving warfarin. Delayed traumatic intracranial hemorrhage is rare and occurred only in patients receiving warfarin. Discharging patients receiving anticoagulant or antiplatelet medications from the ED after a normal cranial CT scan result is reasonable, but appropriate instructions are required because delayed traumatic intracranial hemorrhage may occur.
Collapse
Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Nelluri PK, Lyons R, Severo A, Peterson DW, Chettipally UK, Garza JR. Nerve Growth Potential of FK 506 and Its Analogues – A Systematic review of Controlled Trials in Rats. Canadian Journal of Plastic Surgery 2000. [DOI: 10.1177/229255030000800303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Nerve injuries of the upper extremity seldom regain full preinjury function. Delay in nerve repair, nerve gap and ischemic local conditions are some of the factors attributed as the cause. The proximal axonal segment regenerates in the presence of neuronotrophic factors present in nerve tissue. FK 506 and its nonimmunosuppressive analogues have been shown to influence the growth of axons experimentally. Parallel studies of animals and human beings have demonstrated strong, toxic effects of these agents. Purpose To review systematically data on the role of FK 506 and its analogues in peripheral nerve regeneration of randomized, controlled trials in rats. Reports dealing with the toxic effects of these agents all were reviewed as well. Methods Articles and reviews were identified through a computerized search of MEDLINE from January 1966 to September 1999 by using the terms “FK 506”, “FKBP-12 ligands”, “peripheral nerve regeneration” and “nephrotoxicity, cardiotoxicity and neurotoxicity in FK 506”. Two reviewers assessed the trials independently. Results FK 506 caused dose-related enhancement of axonal growth in all animals that were tested and for all routes of drug administration. Effects of FK 506 when used locally and of its analogues occurred in the same order as those of the parent drug. Conclusions FK 506 and its analogues have been experimentally proven to be potent nerve stimulators. Further studies are warranted in view of the pathological and clinical potential for nephrotoxicity and cardiotoxicity of these agents. The authors proposed an experimental model incorporating a nerve conduit filled with slow release FK 506 at the site of nerve gap or crush, thus decreasing its systemic effects.
Collapse
Affiliation(s)
- Pramod K Nelluri
- Division of Plastic & Reconstructive Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Robert Lyons
- Division of Plastic & Reconstructive Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Antonio Severo
- Christine M Kleinert Institute for Hand & Microsurgery, Louisville, Kentucky
| | | | - Uli K Chettipally
- Department of Emergency Medicine, Kaiser Permanente Medical Center, South Francisco, California, USA
| | - Jamie R Garza
- Division of Plastic & Reconstructive Surgery, University of Texas Health Science Center, San Antonio, Texas
| |
Collapse
|