Clinical Innovations

MRSA Surveillance Changes Can Save Money

Methicillin-resistant Staphylococcus aureus (MRSA) is a primary cause of hospital infection nationally. A team of researchers from the Value Institute, Nursing, and the Infection Prevention Department set out to challenge the health care industry's assumption that patients who tested positive for MRSA over 12 months prior to a hospital admission would still test positive for MRSA colonization. They found that 80 percent of these patients were no longer colonized and were able to be removed from isolation. Implementing this change on just the participating units would save the health system $100,000 annually. Results of this study appear in American Journal of Infection Control. 2014;42(10):1039-43. PMID: 25278390.

Team Champions: Christine DeRitter, BSN, RN-BC, Assistant Nurse Manager, Nursing; Marci Drees, M.D., MS, Infection Prevention Officer and Hospital Epidemiologist; Jennifer C. Goldsack, MChem, MA, MS, Research Associate, Value Institute; Sofia F. Kim, M.D., Physician; Ryan Kirk, Research Assistant, University of Delaware; Michelle Power, BSMT(ASCP), CIC, Infection Control Preventionist; Amy Spencer, MSN, RN-BC, Physician Assistant; and Cynthia L. Taylor, MS, BSN, RN, CRN, Infection Preventionist.

Forecasting and Optimizing Staff Scheduling in the NICU

The Value Institute is collaborating with the neonatal care research team at Christiana Care to analyze and improve scheduling decisions in the Neonatal Intensive Care Unit (NICU). The daily census in the NICU can fluctuate significantly over time. This is a well-studied problem in health care systems. Patient arrivals, patient needs and clinical paths can change dynamically over time. These uncertainties impact planning activities, such as forecasting demand and scheduling resources.

Due to the uncertainty in census, the actual demand for nursing resources may deviate from the scheduled levels which results in suboptimal scheduling, such as extra shifts or cancelled shifts. For example, if the demand exceeds available resources, adding extra shifts is a common measure to meet the desired quality of care standards. Suboptimal scheduling is costly and may significantly impact patient safety, patient outcomes, quality of care, parent satisfaction, and employee satisfaction.

A joint research team is developing analytical forecasting and resource allocation models to optimize scheduling decisions. Our project aims are to precisely identify the census in the NICU over time and inform scheduling decisions considering the changes in NICU utilization. These models may be applied to other areas of Christiana Care to alleviate planning and scheduling issues.

Team Champions: Muge Capan, Ph.D., Health Systems Engineer, Value Institute; Susan Foster, BSN, RN, ANM, NICU Assistant Manager; Gina Moore, BSN, RN, CPHQ, NICU Outcomes Coordinator; Beth Ivey, Senior Systems Analyst; Eric V. Jackson, Jr., M.D., MBA, Associate Director, Value Institute; Robert Locke, D.O., MPH, Director of Neonatal Research; and David A. Paul, M.D., Chair of Pediatrics.

Preventing Opioid-Induced Oversedation

For patients who need opioid medications to manage their pain, careful monitoring is necessary to minimize the many risks that can lead to unintended oversedation. According to The Joint Commission, oversedation due to improper opioid administration is a nationwide issue that negatively impacts quality of care, costs, and patient safety.

Within Christiana Care, a multidisciplinary group with representation from Nursing, Respiratory, Information Technology and the Value Institute is directly tackling this problem through an innovative tool designed to prevent harmful oversedation events.

The oversedation team has created a two-part trigger tool that can provide clinical decision support for patients taking opioids. The combination of the patient's risk profile and the nurse's patient assessment runs through an electronic algorithm, and if a threshold is met, the tool will 'trigger' an alert to the nurse, providing additional information about the patient and suggested actions to take. The project is presently in pilot mode. Next steps include an examination of the current baseline and a full launch of the trigger tool in the pilot unit. The work of the oversedation team is designed to directly align with Christiana Care's Focus on Excellence by promoting a culture of patient safety.

Team Champions: Dean Bennett, RPh, CPHQ, Medication Safety Officer; Dominique Comer, PharmD, MS, Health Economics and Outcomes, Value Institute; and Eric V. Jackson, Jr., M.D., MBA, Associate Director, Value Institute.

A Human Factors Approach to Ebola Virus

To address the Ebola virus in health care settings, the Value Institute is providing human factors consultation to a multidisciplinary team regarding continuing education of frontline staff using simulation training. While Christiana Care routinely trains frontline staff in the use of personal protective equipment (PPE) and other infection control practices, personnel who are likely to care for these patients will start simulation training for correctly donning and doffing of PPE, including Tychem suits. This is a high-stakes simulation where the interaction with the actual equipment that one will be using in the care environment is germane to a successful outcome. A human factors analysis provides the opportunity to assess user behavior, interaction, and performance data to measure how the design of medical devices, equipment, and protocols affects provider performance, quality, and safety.

Team Champions: Marci Drees, M.D., MS, Infection Prevention Officer and Hospital Epidemiologist; and Kristen Miller, DrPH, MSPH, Associate Director of Human Factors, Value Institute.

Turning Large Health Care Data Sets into Clinical Intelligence

Value Institute biostatisticians Paul Kolm, Ph.D., and Zugui Zhang, Ph.D., brought their expertise to the ASCERT study, a unique collaboration under a grant from the National Heart, Lung and Blood Institute of the National Institutes of Health. The study is a partnership between the American College of Cardiology Foundation and the Society of Thoracic Surgeons on the comparative effectiveness of treatments for stable ischemic heart disease.

The five-year observational study compared the long-term effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) to treat coronary artery disease. The study found that over a period of four years or longer, patients undergoing CABG had better outcomes but at higher cost than those undergoing PCI. The findings of the study appear this month in the Journal of the American College of Cardiology as "Cost-effectiveness of Revascularization Strategies: The American College of Cardiology Foundation and The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies" (in press).

Team Champions: Paul Kolm, Ph.D., Biostatistician, Value Institute; William Weintraub, M.D., Director, Center for Outcomes Research, Value Institute; and Zugui Zhang, Ph.D., Biostatistician, Value Institute.

Medical Home Without Walls Decreases Hospital Readmissions

Christiana Care's Medical Home Without Walls program asks whether intensive community based case management outreach can decrease visits by patients who use the emergency room frequently. The Value Institute is evaluating how assigning a case management team consisting of a social worker, nurse and community health worker to high-risk super users of the emergency department empowers patients to seek appropriate primary care before health concerns advance to a need for urgent care.

The Medical Home Without Walls team has submitted a grant to the Patient-Centered Outcomes Research Institute (PCORI). This grant will help Christiana Care evaluate the overall effectiveness of the program. Recently the Delaware-CTR ACCEL, a National Institutes of Health clinical and translational research network, provided funding for the Medical Home Without Walls team to evaluate patient engagement in the program.

Team Champions: Sharon Anderson, MS, BSN, RN, Senior Vice President, Quality, Patient Safety and Population Health Management and Director, Center for Quality and Safety, Value Institute; Diane Bohner, M.D., Medical Director, Medical Home Without Walls, Quality and Patient Safety; Eric V. Jackson, Jr., M.D., MBA, Director of the Center for Health Care Delivery Science and Associate Director, Value Institute; Claudine Jurkovitz, M.D., Senior Physician Scientist, Value Institute; and Susan Smola, JD, MBA, Research Investigator, Value Institute.


Team Spotlight

James Bowen: Senior Systems Engineer

James Bowen, senior systems engineer, Value Institute, specializes in computer science and systems engineering. A member of the Christiana Care team for 12 years, Jim works with research-related databases. He has been involved in implementing and maintaining the PowerChart database from startup and was integral in transitioning the Center for Outcomes Research to the current Value Institute. Jim also supports investigators and research associates by providing and preparing data for research and system evaluation. Among his current projects is Medical Home Without Walls. He is a core member of Delaware-CTR ACCEL, a five-year program designed to provide the resources to develop the infrastructure needed to build sustainable, nationally competitive, clinical and translational research capability in Delaware and South Carolina (www.de-ctr.org).


New Staff at the Value Institute

Education Initiatives

Value Institute and Learning Institute Partner to Improve Health Care Literacy

Summer intern Christine Manta was exposed to every step of the research process with guidance from mentors Seema Sonnad, Ph.D., Value Institute, and Jacqueline Ortiz, MPhil, director of Cultural Competency and Language Services, Learning Institute. Christine's work was a result of her participation in the INBRE Intern Program, co-sponsored by the Value Institute, which offers opportunities for students to participate in research activities and work with experienced mentors during the summer. Students from Drexel University, Mount St. Mary's University, University of Delaware, and Wake Forrest University spent their summer months working on a variety of projects sponsored by the INBRE Intern Program or the Value Institute Intern Program.

"Consent to Treat Forms Fall Short of Providing Information to Guide Decision Making," Christine's summer project, focused on health care literacy and the informed consent process. The goal of the study was to determine how the informed consent forms at Christiana Care could be improved to help patients better read and understand documents that require their signature. Her research demonstrated that altering the format or type of information that patients receive is a good first step in improving the informed consent documents. Christine shared that she greatly enjoyed her experience working at the Value Institute!


Value Institute Summer 2014 Interns: (left to right) Christine Manta, Alisa
Chanchenchop, John Hafycz, Angela Berry, Christopher Mascioli, Anne Pohl,
Andrew Freeman, and Rachel Singleton


Getting Involved

The Value Institute is built on a model of high-level collaboration. We partner with academic institutions, corporations, health care professionals, and thought leaders who share our commitment to improving health care value and delivery by turning evidence into real-world solutions. We cultivate relationships with patients, clinicians, sponsors, and professional colleagues who recognize the importance of improving health care delivery and health outcomes, organizational excellence, and quality and safety.

Christiana Care providers are cordially invited to partner with the Value Institute on collaborative research, including clinical trials, database studies, and demonstration projects.

As of December 22, 2014, the Value Institute has supported 169 consultations from clinical departments across Christiana Care. To request a consultation, visit the Portal. Value Institute staff members are actively involved in 77 research projects in a variety of disciplines (see infographic).


Awards

ACCEL Research Award Winners

Value Institute scholars are among the year two grant recipients for Delaware-CTR ACCEL, a National Institutes of Health-funded biomedical research network that promotes sustainable, nationally competitive, clinical, and translational research programs. Awardees are:

Ryan Arnold, M.D., MS, Emergency Medicine and clinical investigator, Value Institute – Identifying Effective Therapies in Sepsis

Jennifer Goldstein, M.D., Internal Medicine physician and Value Institute scholar – A Systematic Approach to Patient Engagement in the Discharge Process

David Kahn, D.O., Neurology and Neurological Interventional Surgery – Combining Resting EEG and Event Related Potentials to Predict Outcome after Coma

Susan Smola, JD, MBA, Senior Clinical Researcher, Value Institute – Medical Home Without Walls: Patient Engagement Informing a Randomized Clinical Trial

Michael Vest, D.O., Pulmonary and Critical Care Medicine – Energy Balance and Clinical Outcomes of Obese, Mechanically Ventilated Patients in the Intensive Care Unit

Sandra Weiss, M.D., Cardiovascular Disease and Interventional Cardiology – Effects of Radial Artery Catheterization on Radial Dimensions and Endothelial Function

Daniel Elliott, M.D., MSCE, FACP Associate Chair of Research, Department of Medicine; Research Scholar, Value Institute – Improving Population Health Through Linked Ambulatory Electronic Health Records

Claudine Jurkovitz, M.D., MPH, Senior Physician Scientist, Value Institute – Linking Data for Kidney Care

Selected Publications

Sonnad SS, Mascioli S, Cunningham J, Goldsack J. Do patients accurately perceive their fall risk? Nursing. 2014; 44(11): 58-62. PMID: 25321438

Jesus JE, Michael GE. Organ donation and the emergency department: Ethically appropriate and legally supported. The Journal of Emergency Medicine. 2014; 47(2): 209-12. PMID: 24881894.

Wu P, Gunzler D, Lu N, Chen T, Wymen P, Tu XM. Causal inference for community-based multi-layered intervention study. Statistics in Medicine. 2014; 33(22): 3905-18. PMID: 24817513.

Rosen MA, Sampson JB, Jackson EV Jr, Koka R, Chima AM, Ogbuagu OU, Marx MK, Koroma M, and Lee BH. Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone. British Medical Journal, Anaesthesia. 2014; 113(3): 410-5. PMID: 24833727.


Selected Presentations

Capan M, Ivy J, Huddleston J. Informing Resuscitation Decisions in Acute Care by Capturing Provider-Specific Model Uncertainty. Presented at: INFORMS Annual Meeting; 2014 Nov 9-12; San Francisco, CA.

Drees M, Brown J, Gillin T, Protokowicz N, Fagraeus L, Panchisin T, Booker B, Dombroski G, Emberger J, Maheshwari V, Fulda G, Dressler R. Optimization of PEEP as a strategy to reduce ventilator-associated events. Poster presented at: IDWeek; 2014 October 8-12; Philadelphia, PA.

Estock J, Mascioli S, Alders V, Cunningham J. A Method for Creating Organizational Capacity to Deliver Value. Poster presented at: American Nurses Credential Center National Magnet Conference; 2014 October 8-10; Dallas, TX.

Zhang Z, Kolm P, Ewen E, Spertus JA, Boden WE, Weintraub WS. Effects of Optimal Medical Therapy on Health Status in Patients With or Without PCI for Stable Coronary Disease: Results from COURAGE. Presented at: American Heart Association Scientific Sessions; 2014 November 15-19; Chicago, IL.

Collaborations is a quarterly release of Value Institute news and events. Visit our website to read our 2014 annual report, see our video and to learn more about the Value Institute.