title: reducing harm in pediatrics: a davies story · head injury ct scan and quality shireen m....
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Title: Reducing Harm in Pediatrics: A Davies Story
Session 132, March 7, 2018
Speakers:
Brian R Jacobs, MD,CIO, CMIO, Children’s National Health System
Shireen M. Atabaki, MD, MPH, , Children’s National Health System
Jonathan Palma, MD, MS, Stanford Children’s Health
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Brian R. Jacobs, MD, Children’s National Health System
Shireen Atabaki, MD, MPH, Children’s National Health System
Jonathan Palma, MD, MS, Stanford Children’s Health
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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AgendaIn the first use case the team at Children’s National Health System will present their successful efforts to increase patient engagement and improve patient outcomes, through their health IT optimization for pediatric concussion care
• Background
• Local Problem
• Governance, Design and Implementation
• Value Derived
• Future Advancement
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Learning Objectives• Understand the role of workflow-integrated clinical decision support
in improving outcomes
• Learn about rapid clinician adoption of technology and knowledge translation
• Understand financial savings which can result from integrated EHR utilization
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Head Injury CT Scan and Quality Shireen M. Atabaki, MD, MPH
Medical Director, Informatics, Program Director, Telemedicine
Children’s National Health System
Brian R Jacobs, MD
CIO, CMIO, Children’s National Health System
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Background
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Pediatric Concussion and CT Data
Most frequent diagnosis for injured child is:
HEAD INJURY
• Each year in the US:
– 5 million children
– Over 1 million ED visits
• 4 million pediatric CTs
– 20 fold increase 1995-2003
Faul M, Centers for Disease Control, 2010
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Partnership Launching with Bear Institute in 2013
• 1st pediatric Health IT Institute in the country
• Mission is to foster innovation, advance clinical care, and create a world-class IT structure to improve outcomes and service.
• Institute works to accelerate the development of fully-integrated , accessible EHR via advanced health IT capabilities
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• 313-bed acute care hospital• 2 pediatric emergency departments• Level I trauma center• Critical care transport program• Community-based primary care network• Primary care offices in DC and MD• 7 regional outpatient centers• Ambulatory surgery center• School nurse program• Medical collaborations across the region• Mobile health services
Serving over 219,000 patients/year: regionally, nationally, and from 21 countries
• $ 1.1 B Budget Health SystemIn FY 17:• Discharges – 15,554• Emergency Room Visits – 120,648• Outpatient Visits – 560,810• Surgery Cases – 17,535
Children’s National At a Glance
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How Health IT supports our mission• Supports Organizational Transformation – Integrated and interoperable Health IT
systems support evidence based, high quality care for kids, with improved outcomes
and an overall reduction in cost. e.g. decision support and practice guidelines
• Patient Engagement – Innovating the way we use Health IT can empower our
patients/families to take an active role in their care. e.g. patient portals, mobile device
tools, and Telehealth
• Improvement in Care Delivery, Outcomes, and Patient Safety – Robust Health IT,
providers have data and devices at the bedside, allowing them to spend more time with
their patients. e.g. Ambulatory EHR
• Propelling Innovation and Research – Sophisticated Health IT capabilities enable
advances in medicine. e.g., genomics, matching patient information with a database of
open clinical trials for research and population health
.
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Local Problem
12March 5, 2018
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• Risks of lethal malignancies
– Cranial CT = 100 x radiation of CXR
– CT in 1st 22 years of life = 300% increase in lifetime cancer
– 1/1100 infants w/ lethal malignancies
• NCI and FDA issued warnings in 2001
March 5, 2018Pearce et al., Lancet, 2012
Pediatric Concussion and CT Radiation
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PECARN CT Decision Rules, 2009 • N=44,000 children• CDS to detect clinically important brain injury• 99.9% Negative Predictive Value
Kuppermann, Holmes, Dayan, Hoyle, Atabaki et al., Lancet, 2009
Evidence Based Medicine at CNHS
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• 10 fold variation btw Providers in CT
• CT rates 30%
• 1000 CTs annually
• Over 92% of CT scans were normal
• Percentage did not improve 2009-11
• Traditional KT is slow – 10-13 years
Zerhouni, NIH
Pre-implementation CT Rates
Provider
% O
rderi
ng
a H
ead
CT
16March 5, 2018
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How Health IT was Utilized
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Evidence Based
Medicine
Improved Outcomes
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CNMC CPOE Decision Support
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21
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Governance
• Goal: Decrease % of children with concussion who had a head CT ordered in our Emergency Departments
• Team
– SMEs in ED/Trauma/ Nursing/ IT/ Education
– Project Manager
– Analyst
– Project Architect
Patient Safety
Quality Improvement
Evidence Based
Medicine
Health ITBest
Concussion
Care
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Previous Process
March 5, 2018
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Current Process
March 5, 2018
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Value Derived
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Outcomes: Radiation & Cost Reduction
• Radiation Reduction:
– 44% relative reduction in CT scan rate
Pre: 1000 (27%) to Post: 444 (11.9%)
• Cost Reduction:
– 556 avoided head CT scans
– $875,144 cost reduction per year
– No untoward outcomes
March 5, 2018
Atabaki, Jacobs et al., Ped Quality & Safety, 2017
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Proportion of Concussion Patients with CT
March 5, 2018
0%
5%
10%
15%
20%
25%
30%
35%Intervention
y = -0.0138x + 0.258R2 = 0.7621
y = 0.0002x + 0.2394R2 = 0.0002
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Outcomes Data
March 5, 2018
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Future Advancement
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Goal #1: Health IT for Knowledge Translation to Improve Quality
March 5, 2018
• EBM models can be transferred across EHRs
• Abdomen CT (trauma, appendicitis)
• Head CT (seizure, headache, VP shunt)
• City wide collaboration
• National and International EBM dissemination
• Provider education strategiesMeaningful Use in Oklahoma & the District of Columbia, AHRQ 2015
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Goal #2: Shifting the Paradigm of Concussion Care
March 5, 2018
• CDC Funded Project
– Created effective diagnostic tools for ED
– Created education for outpatient
– Communication to school and PCP
– Improve Outcomes
CDC Grant 1U49CE001385-01
Zuckerbraun, Atabaki, Collins, Gioia et al, Pediatrics, 2015
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Mobile Apps for Patients and Families
March 5, 2018
• Developed a mobile health solution that communicates via the EHR to the concussion screening information
– Allows for patients to be Rxed mobile App and go home with a concussion check-list and daily reminders
– Provides secure communication with the patient’s school nurse and primary care physician
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Stanford Children’s HealthOver 80 ACGME-accredited
residency & fellowship
programs
500,000+Ambulatory Patient Visits Per Year
60+ Bay Area Locations
Our obstetric, neonatal
& developmental
medicine services are
all in one location;
the only children’s
hospital in the Bay
Area and one of a few
in the country to offer
all three
725+Stanford Medicine Doctors
New family friendly,
environmentally
sensitive, &
technologically
advanced children’s
hospital with
361 inpatient beds
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• Nephrotoxins and Acute Kidney Injury
• Clinical Case
• NINJA Collaborative
Local Problem
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• Hospitalized children have become more ill, more complicated
More therapies and
polypharmacy
Nephrotoxins are ... toxins
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• Nephro means kidney and toxin means, well, toxin
– Cause acute kidney injury (AKI) and failure
– AKI increases mortality, length of stay (LOS), and chronic kidney disease (CKD)
Nephrotoxins are ... toxins
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Clinical Case
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Clinical Case
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Kidney International, 2016
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• Identify nephrotoxic medication (NTMx) exposure:
• Aminoglycoside for > 3 days (or)
• > 3 nephrotoxins simultaneously
• Recommends screening for AKI daily using serum creatinine
• Increase awareness, prompt conversation about nephrotoxins
NINJA CollaborativeNephrotoxic Injury Negated by Just-in-time Action
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NINJA CollaborativeNephrotoxic Injury Negated by Just-in-time Action
Mission: Eliminate all preventable cases of nephrotoxic medication associated AKI in hospitalized children
Vision: Children should only get the nephrotoxic medications they need for the duration they need them
Armed with a Mission, a Vision, a list of nephrotoxins, and …
actually, not much else
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• Identification of the Project Team
• Development of the Workflow
• Definition of Intended Outcomes
Design and Implementation
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Nephrology: Scott Sutherland, MD
Pharmacy: Tiffany Tesoro, PharmD
Clinical Informatics: Jonathan Palma, MD, MS
IS Analytics: Emilie Tan, Analyst
Identification of Project Team
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IntroductionDefinition of
RequirementsProposed Workflow
Workflow Iteration
• Project Team
• NINJA goals/
objectives
• Define roles
• Establish
timeline
• Identify nephrotoxin-
exposed patients
• Communicate
exposure to care
team
• Define clinical
intervention and
recommendations
• Electronic report
• Communication
plan (PharmD)
• Recommend:
screen for AKI,
discuss tx
regimen
• Review and
revise IT solution
• Grow
relationship with
clinical teams
• Refine recs:
change, d/c
meds; adjust
dosing
Development of the Workflow
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Definition of Intended Outcomes
Aligned with the NINJA Collaborative:
• Rate* of Nephrotoxic Medication (NTMx) exposure
• Rate* of Acute Kidney Injury AKI (Creatinine > 1.5x baseline)
*per 1000 non-ICU patient days
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• Clinical Workflow
• IT Solution: NINJA Report
– Structure
– Logic
– Evolution
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How Health IT was Utilized
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👩
�👩👧👦
�
Clinical
PharmacistCare Team
Laboratory
screening
Medication
adjustment
s• Identify pts with
NTXm exposure
• Communicate exposure
to care team
• Recommend screening
labs (daily creatinine)
• Consider labs: serum creatinine, drug levels
• Consider meds: dosage, duration, and alternative
agents
Clinical Workflow
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NINJA Collaborative
Nephrotoxic Medications Nephrotoxin exposure Recommendation
✅ Aminoglycoside for > 3
days
(or)
✅ > 3 nephrotoxins at once
� Screen for AKI daily
using serum creatinine
� Check drug levels
� Discuss dose/duration of
and alternatives to
nephrotoxic medications
Goldstein et al. Kidney International,
2016.
aMedications counted for 7d following
administration (long half-life); all others
counted for 48h.
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👩
�
👩👧👦�
Clinical
Pharmacist
Care Team
Laboratory
screening
Medication
adjustment
s
�
NINJA
Report
Clinical Workflow with IT Solution
• Run NINJA report,
identify pts with NTXm
exposure
• Communicate exposure to
care team
• Recommend screening labs
(daily creatinine)
• Consider labs: serum creatinine, drug levels
• Consider meds: dosage, duration, and alternative agents
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Nephrotoxic Medications Ordered
(Start, End, Last Dose)
Laboratory
Information
(Creatinine)
Patient Information
(MRN, Name,
Location)
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> 3 nephrotoxins
simultaneously
Aminoglycoside for
> 3 days
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• Content
– Added Stem Cell Transplant and Hematology/Oncology
– Expanded nephrotoxin list from 45 to 61 items
• Implementation
– SAP Business Objects report (-24h) to Epic Reporting Workbench (real-time)
NINJA Report: Evolution
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Clinical Case
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NINJA
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NINJA
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NINJANINJA
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NINJANINJA
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• Value Derived
– Reduced nephrotoxin exposure
– Reduced AKI
• Clinical Impact
Value Derived
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62*358 pt days screened/wk = 18,616 pt days screened /year
Value Quantified
• Nephrotoxin Exposure
– Stanford Children’s intervention reduced exposure rate by 39%
– Annual exposure rate = 404 exposures/year
Prevented 158 NTMx exposures per year
• AKI
– Intervention reduced AKI rate by 44%
– Annual AKI rate = 113 cases of AKI/year
Prevented 50 AKI events per year
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• Continued adjustments (+/-) to nephrotoxin list and logic
• Extension to ICU/CVICU population (high risk populations where a dedicated pharmacist is already present)
• Augmentation of AKI prevention with intelligent alerts, e.g. for IV contrast as an additional exposure
• Extension to other teams (prompting hiring of additional clinical pharmacists)
• Enhancing report with medication levels
Ongoing Improvements
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Questions?
Jonathan Palma, MD, MSClinical Associate Professor, Neonatal-Perinatal Medicine
Program Director, Clinical Informatics Fellowship
Medical Director, Clinical Informatics Innovation
Twitter: @jonpalma180
LinkedIn: @jonpalma
http://profiles.stanford.edu/jonathan-palma
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