Clinical Innovations

Data-Linking Project Aims to Improve Care Coordination for Chronic Kidney Disease Patients

Chronic kidney disease (CKD) is prevalent in the United States, with one in 10 adults having some level of CKD. In Delaware, 2,071 patients were in chronic renal replacement therapy in 2011. CKD patients have multiple conditions and see multiple health care providers, potentially leading to drug interactions and redundant testing.

A multidisciplinary team of investigators, system engineers, data analysts and biostatisticians from Christiana Care and the Value Institute, Nemours/Alfred I. duPont Hospital for Children, Nephrology Associates and the University of Delaware hopes to examine the effectiveness of the health care delivery system in providing and coordinating care for CKD patients in Delaware. To do so, the team will link nonintegrated clinical data from multiple sources to create longitudinal records with the goal of creating a better understanding of current care delivery processes and improving their quality and coordination. Based on these data, the team will develop models and methods for predicting hospital admission patterns after an outpatient visit. Finally, it will examine the transitions from pediatric to adult care of young adults with CKD.

The team plans to combine records from the Christiana Care Kidney Transplantation Program, Nemours/Alfred I. duPont Hospital for Children and a large nephrology practice to establish its study population. These records will be linked to Christiana Care acute care electronic health records to identify hospitalizations and emergency visits; to the Medical Group of Christiana Care records to identify primary care visits; to Medicaid and Medicare claims to determine resource utilizations; and to the United States Renal Disease System to identify patients in renal replacement therapy. The team will use time-series and predictive analytics techniques such as machine learning to predict hospitalizations.

The CKD data-linking project is the first step toward building a unified operational platform that will decrease care fragmentation in order to improve patient care coordination and outcomes.

Team Champions: Claudine Jurkovitz, M.D., MPH, Value Institute; Edward Ewen, M.D., Value Institute; James Bowen, BA, Value Institute; Tom Laughery, BS, Value Institute; Sarahfaye Heckler, BA, Value Institute; Timothy Bunnell, Ph.D., Nemours/Alfred I. duPont Hospital for Children; Hagit Shatkay, Ph.D., University of Delaware; John Swanson, M.D., Kidney Transplant Program, Department of Surgery; Joshua Zaritsky, M.D., Nemours/Alfred I. duPont Hospital for Children; Rubeen Israni, M.D., MSCS, Nephrology Associates.

Value Institute Usability Lab: A Human Factors Approach to Advancing Patient Safety

Human factors approaches underpin current best practices in patient safety and quality improvement science, offering an integrated, evidence-based, and coherent approach to improving the science behind health care delivery. Usability testing is the formal method of systematically observing and recording representative members of real end-users performing real tasks. These tasks are performed with a real or simulated product and assessed against measurable criteria. The demand for usability testing is becoming increasingly important as health care moves toward a commitment of zero patient harm and higher value care.

The usability lab is an integral part of the human factors program at the Value Institute. The goal is to provide evidence to support the selection and implementation of safe, user-friendly medical products and develop solutions that improve the usability of health care providers’ tools and systems. The lab promotes collaboration across Christiana Care to improve the depth of understanding of human factors and usability in product design, critical thinking, acquiring problem-solving skills, and recognizing system vulnerabilities.

The inaugural evaluation at the Value Institute Usability Lab in conjunction with the Virtual Education and Simulation Training (VEST) center is a simulated use of infusion pumps. Recognized as an indispensable tool in hospital care, infusion pumps are used to administer critical fluids, including high-risk medications. However, given their complex design, errors can result during the use of these pumps, causing significant implications for patient safety.

In order to address questions important for the design and development of system-wide expansion, simulated use provides the opportunity to detect and analyze potentially dangerous problems in the design of infusion pumps that can cause or allow avoidable errors.

Team Champions: Dean Bennett, RPh, CPHQ, Medication Safety Officer, Quality and Patient Safety; Sue Coffey-Zern, M.D., Director, Virtual Education and Simulation Training center; Gwen Ebbert, MSN, RN-BC, Staff Education Specialist, Nursing Quality and Safety; and Kristen Miller, DrPH, MSPH, Associate Director of Human Factors, Value Institute.


Computerizing Physician Orders and Medication Records Reduces Costs, Improves Flexibility

Preliminary findings from an ongoing study by a team of Value Institute researchers and Christiana Care collaborators were presented at the Fifth Annual Workshop on Health IT and Economics (WHITE) in Washington, D.C.

Value Institute research associate Jennifer Goldsack, MChem, MA, MS, presented “Implementation of eMAR and CPOE Reduces Costs and Increases Flexibility on Hospital Units” at the October 2014 conference. WHITE is organized by the Center for Health Information and Decision Systems at the University of Maryland and is designed to showcase the latest research, inspire innovation, and accelerate health care transformation at the intersection of health IT and economics.

The short presentation on the use of electronic medication administration records and the computerized physician order entry system shared preliminary findings from a Christiana Care Chairs’ Leadership Council-funded study that is a collaboration among Edmondo Robinson, M.D., MBA, FACP, physician-in-chief of Wilmington Hospital, Christiana Care associate chief medical officer and Value Institute scholar; Value Institute research associate Jennifer Goldsack, MChem, MA, MS; Betty Brady, RN, IT program manager; and Shirley Moran, MS, RN, NE-BC, vice president of Patient Care Services. The study has been supported by graduate students through the VI Intern Program. This presentation was part of a larger body of ongoing work that includes, to date, a published manuscript and other presentations at the 2014 AcademyHealth Annual Research Meeting and the 2014 Robert Wood Johnson Foundation Clinical Scholars’ Program National Meeting.

Team Champions: References included in article.


The Sepsis Incidence Dataset Defines the Burden of Sepsis at Christiana Care

Nationally published statistics have identified sepsis as the leading cause of in-hospital death and the most expensive medical condition for hospitalized patients. However, unclear definitions of sepsis and the lack of a sound epidemiological framework make it difficult to estimate the magnitude of the problem. The Sepsis Value Improvement Team and the Value Institute have partnered to understand the true burden of sepsis at Christiana Care in order to improve care and decrease mortality.

Criteria to identify sepsis were derived by reaching consensus opinion among 12 leading Christiana Care clinicians responsible for the care of sepsis patients. These criteria include both patient-centered and physician-centered markers for sepsis. The result was the Sepsis Incidence Dataset, which contains 50,150 consecutive admissions to Christiana Care during a 12-month period and captures the identification of 15,000 sepsis patients – an incidence rate of nearly 30 percent. These results were validated by an independent panel of four physicians hand-reviewing medical records of a subset of the population to verify the presence of severe sepsis. Future work in this area will use the dataset to complete a full analysis of the performance of the Cerner St. John Algorithm, which is widely used in clinical settings to identify early-stage sepsis. Future work also will include collaboration with Christiana Care’s VEST Center to perform simulation testing on how clinicians detect sepsis and respond to clinical decision support.

Team Champions: Ryan Arnold M.D., Emergency Medicine and Clinical Investigator, Value Institute; Tom Laughery, BS, Senior Systems Analyst, Value Institute; Kristen Miller, DrPH, MSPH, Associate Director of Human Factors, Value Institute; Zugui Zhang Ph.D., Senior Biostatistician, Value Institute; Eric V. Jackson, M.D., MBA, Director, Health Care Delivery Science, Associate Director, Value Institute.


Improving Data Collection Capabilities Through the Introduction of REDCap

REDCap, or Research Electronic Data Capture, is a secure, web-based application used by more than 1,300 institutions in 88 countries to create, distribute, and share surveys, forms, and the data they create. The Value Institute collaborated with the IT department and users from other departments throughout Christiana Care to implement REDCap within the health system. The Value Institute also partnered with outside institutions with experience implementing REDCap to receive invaluable guidance to assure the smooth implementation and adoption of REDCap at Christiana Care.

REDCap can be used for research, organization, and quality improvement purposes. Any data collection activity for which a user currently might use Survey Monkey, Teleform, or paper forms can be accomplished in REDCap. REDCap can be used to distribute surveys (anonymous or identified) or to capture data in forms, and supports branching logic to save time and collect accurate, complete data. It supports longitudinal projects or projects with separate research arms. REDCap has an easy user interface that guides users through developing forms and surveys and organizing database and data definitions. REDCap also has built-in features for data validation and quality testing, tracking form completion, scheduling follow-up visit reminders, generating summary statistics, and reporting and exporting of datasets in multiple formats. REDCap allows multiple users to work on the same project with different access rights for each user, and it maintains a complete log for audit purposes.

Anyone with a Christiana Care employee identification number can request access to Christiana Care’s REDCap. For additional details, contact REDCap department leads, or visit Project REDCap.


Expanding Lean Six Sigma Program Develops Home-Grown Quality-Improvement Leaders

Four years into its existence, Christiana Care’s Lean Six Sigma program is rapidly expanding organizational capacity to deliver value within the health system. By training employees in departments throughout Christiana Care as quality-improvement experts, the program creates employees who can recognize opportunities, identify root causes of problems, develop quality-improvement interventions, and deliver meaningful, sustained improvements in health care from the inside out. The program is offered through the Value Institute’s Center for Organizational Excellence, sponsored in partnership with the internationally recognized Juran Institute quality-management company.

On Feb. 16, Christiana Care graduated its first class of Lean Six Sigma Yellow Belts, a group of about 100 employees from 11 departments throughout Christiana Care who participated in training that introduced them to Lean Six Sigma quality-improvement principles. About 30 members of the inaugural Yellow Belt class took an additional exam to earn certification as Rapid Process Improvement leaders. Under the expert guidance of senior organizational excellence consultants, E. J. Johnson, Ph.D., ChE, MSChE, MBA, LSS MBB, senior organizational excellence consultant, Value Institute and Derek Vandersteur, MSM, BSIE, MBB, senior organizational excellence consultant, Value Institute this year’s program was enhanced significantly to add rigor to the teams’ performance improvement projects.

This fiscal year, the program expanded to include its first Black Belt class – a group of eight Christiana Care employees working toward advanced Lean Six Sigma certification – as well as offering Green Belt and Yellow Belt training to candidates outside of Christiana Care for the first time to help expand organizational capacity among partner organizations.

Along with the new Yellow Belt and Black Belt programs, Christiana Care is in its third year of offering intensive Green Belt training. About 60 employees have completed the months-long training, and another 30 are in a current class. The training process for all belt levels includes each candidate identifying and completing a quality improvement project within his or her individual area of expertise. Projects conducted by Christiana Care’s first two Green Belt classes have resulted in the elimination of waste and errors; greater patient satisfaction, efficiency, effectiveness and affordability of care; improved patient outcomes; and a remarkable 15-to-1 return on investment. For its investment of $200,000 in the two Green Belt classes, Christiana Care already has seen a $3 million return on that investment.

Program leaders: Vernon L. Alders, MHCDS, MBA, MSW, Corporate Director, Organizational Excellence, Director, Center for Organizational Excellence, Value Institute; Krystal M. Coles, BS, LSS MBB, Senior Organizational Excellence Consultant, Value Institute; June Estock, MSN, RN, CPHQ, LBB Senior Organizational Excellence Consultant, Value Institute; Jamie Hedrick, MBA, MS, Organizational Excellence Consultant, Value Institute; Keith Heitz, MTS, CLSSGB, CPhT, Organizational Excellence Consultant, Value Institute; E. J. Johnson, Ph.D., ChE, MSChE, MBA, LSS MBB, Senior Organizational Excellence Consultant, Value Institute; Derek Vandersteur, MSM, BSIE, MBB, Senior Organizational Excellence Consultant, Value Institute.


Colloquium Facilitates Collaboration and Coordination in Development of Trigger Tools

The Value Institute recently hosted a Trigger Tools Colloquium with the goal of fostering communication and collaboration among teams working to prevent harmful events. The colloquium recognized the innovative work throughout Christiana Care surrounding several “trigger tools” under development that can be used to predict harmful medical events and accelerate and improve the response to those events.

The colloquium, held Jan. 23 and moderated by Value Institute associate director Eric V. Jackson, Jr., M.D., MBA, brought together teams working on three separate projects: the Christiana Early Warning System, a trigger tool being developed to identify patients who are deteriorating physiologically; a two-part trigger tool designed to prevent opioid-induced oversedation; and the development of tools to identify sepsis cases, including the recently developed Sepsis Incident Dataset. While the projects tackle different health care issues, all share a similar framework and similar data collection methods, and analytic needs.

The colloquium allowed clinicians, researchers, IT professionals and other participants to update each other on the progress, status, challenges and next steps in their projects, as well as finding opportunities for collaboration and coordination of related efforts. The colloquium also served to educate participants about the depth and breadth of services available through the Value Institute to support the trigger-tools projects, such as data collection and analysis assistance.

Team Champions: Eric V. Jackson, Jr., M.D., MBA, Director, Health Care Delivery Science, Associate Director, Value Institute; Ryan Arnold, M.D., Emergency Medicine and Clinical Investigator, Value Institute; Dean Bennett, RPh, CPHQ, Medication Safety Officer, Quality and Patient Safety; Michele Campbell, RN, MSM, CPHQ, FABC, Vice President, Patient Safety and Accreditation, Quality and Patient Safety; Muge Capan, Ph.D., Health Systems Engineer, Value Institute; Tze Chiam, Ph.D., Associate Director of Clinical Informatics, Value Institute; Dominique Comer, PharmD, MS, Senior Clinical Researcher, Value Institute; Stewart Constance, BS, PA-C Chief, Critical Care, Department of Medicine; Robert Dressler, M.D., MBA, Vice Chair, Department of Medicine; June Estock, MSN, RN, CPHQ, LBB, Senior Organizational Excellence Consultant, Value Institute; Adebayo Gbadebo, MBA, Senior Systems Analyst, Value Institute; Tom Laughery, BS, Senior Systems Analyst, Value Institute; Vinay Maheshwari, M.D., Director, Medical Critical Care; Susan Mascioli, MS, BSN, RN, CPHQ, NEA-BC, Director, Nursing Quality and Safety; Kristen Miller, DrPH, MSPH, Associate Director of Human Factors, Value Institute; Badrish Patel, M.D., Medical Director, Medical Intensive Care Unit; Elizabeth Schreppler, manager, IT; Maureen Seckel, APN, ACNS-BC, CCNS, CCRN, FCCM, Medical Pulmonary Critical Care; Larry Trach, IT Consultant, EMR Connect; Zugui Zhang, Ph.D., Senior Biostatistician, Value Institute.

Team Spotlight Dominique Comer: Senior Clinical Researcher
		Dominique Comer, Pharm.D., MS, senior clinical researcher, Value Institute, specializes in health economics and outcomes research. Comer is a member of the Center for Health Care Delivery Science and serves as a research lead for the Preventing Opioid-Induced Oversedation project. Her manuscript, “Usefulness of Pharmacy Claims for Medication Reconciliation in Primary Care,” recently was accepted for publication by the American Journal of Managed Care. This study focused on the potential of currently available pharmacy claims within the electronic health record to impact care. Comer recently was named a PhRMA Foundation Featured Scientist and she was a previous recipient of the PhRMA Foundation Postdoctoral Fellowship in Health Outcomes. She joined the Christiana Care team in August 2014.

Education Initiatives

Meet Student Researcher Rachel Brown

Involving students in research provides significant benefits to them, their research mentors and the sponsoring institutions. Developing a strong student research program has been a goal of the Value Institute from its inception. To fulfill this goal, the Value Institute has partnered with academic programs, including the Master of Science program in Biostatistics and the Master of Public Health program at Drexel University, as well as the undergraduate Medical Scholars Program at the University of Delaware.



Brown is a recent University of Delaware graduate, a medical scholar with a triple major in biology, French and liberal studies. She is spending her gap year at Christiana Care and recently learned that she has been accepted to the Philadelphia College of Osteopathic Medicine, where she will matriculate in August with the goal of becoming a family medicine physician. Brown’s advisor, David Barlow, Ph.D., director of the University of Delaware's Center for Premedical and Health Profession Studies, initiated her association with the Value Institute. Brown is interested in clinical research which served as a vehicle to strengthen her medical school applications and to provide her with insight into life in academic medicine.

Brown is providing significant assistance on three projects: two in neurocritical care, mentored by Valerie Dechant, M.D., medical director of Christiana Care’s Lanny Edelsohn, M.D. Neuro Critical Care Unit, and the third with Value Institute research associate Jennifer Goldsack, MChem, MA, MS. These projects have afforded her the opportunity to answer both clinical and research questions as well as to spend time in clinical areas shadowing physicians and attending Christiana Care grand rounds and conferences. Through these projects, Brown has written protocols that were submitted to Christiana Care’s Institutional Review Board, built a REDCap database, conducted chart reviews and performed basic statistical analyses.

Brown appreciates the fact that everyone considers her to be a productive part of their research teams. Brown is a great example of the role student’s play in Value Institute collaborations to support research throughout Christiana Care.


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 reality. 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.

You can partner with the Value Institute on collaborative research, including clinical trials, database studies, and demonstration projects. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. One of our team members will then contact you to discuss your research plans.



Awards

ASAM Annual Conference Program
Planning Committee Award

Value Institute scholar Terry Horton, M.D., FACP, chief of Christiana Care's Division of Addiction Medicine and medical director of Project Engage, has been named the 2015 winner of the American Society of Addiction Medicine (ASAM) Annual Conference Program Planning Committee Award. The award, for Horton’s work on Project Engage, an innovative and nationally recognized early addiction intervention program that he established in 2008, will be presented April 25 in Austin, Texas, during the ASAM's 46th annual conference.

2015 Focus on Excellence Awards

Christiana Care’s 12th Annual Focus on Excellence Awards were announced Jan. 20, recognizing work being done to promote the Christiana Care Way. The Value Institute was well represented at the awards ceremony. Sharon Anderson, MS, BSN, RN, FACHE, director of the Value Institute’s Center for Quality & Patient Safety and senior vice president of Quality, Patient Safety & Population Health Management, served as the master of ceremonies, while several Value Institute staff served as volunteers and judges. Value Institute staff and scholars were involved in the following award-winning projects:

• Chronic Obstructive Pulmonary Disease (COPD) Care Improvement (honorable mention)
• Decreasing Emergency Department Blood Culture Contamination
• Embracing the Huddle in a Resident Teaching Clinic
• Impact of Performing Active Surveillance on Known MRSA-Positive Patients Admitted to Christiana Hospital
• Implementation of an Electronic Sepsis Advisory Trigger
• Let’s Get Rid of Those Bugs: Organizing a VIT to Improve Outcomes Related to Sepsis
• Nutrition Coaching Reduces Adolescent Obesity
• Onsite Ultrasound Improves Patient and Staff Experience
• Reducing AccuDose Stock-outs in the Christiana Hospital Emergency Department
• Successful Integration of the Palliative Care and Heart Failure Teams

Selected Publications

Halbert CA, Cipolle MD, Fulda G, Tinkoff GH, Pirrung JM, Kalina M. Admission to an observational unit improves length of stay for patients with mild traumatic brain injuries. The American Surgeon. 2015; 81(2): 176-9. PMID: 25642881

Novitsky A, Tuttle D, Locke RG, Saiman L, Mackley A, Paul DA. Prolonged early antibiotic use and bronchopulmonary dysplasia in very low birth weight infants. American Journal of Perinatology. 2015; 32(1): 43-8. PMID: 24792766.

Rosini JM, Laughner J, Levine BJ, Papas MA, Reinhardt JF, Jasani NB. A randomized trial of loading vancomycin in the emergency department. Annals of Pharmacotherapy. 2015; 49(1): 6-13. PMID: 25358330.

Zhang Z, Kolm P, Grau-Sepulveda MV, Ponirakis A, O’Brien SM, Klein LW, Shaw RE, McKay C, Shahian DM, Grover FL, Mayer JE, Garratt KN, Hlatky MH, Edwards FH, Weintraub WS. Cost-effectiveness of revascularization strategies: Results from The American College of Cardiology Foundation and The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies (ASCERT). Journal of the American College of Cardiology. 2015; 65(1): 1-11. PMID: 25572503.


Selected Presentations

Bhamidipati S, Elliott D, Robinson E, Sonnad SS, Jordan J. Interdisciplinary admissions and rounding to improve patient outcomes. Presented at: Hospital Medicine 2015. Society of Hospital Medicine Annual Meeting; 2015 Mar 29-Apr 1; National Harbor, MD.

Horton T Jurkovitz C, Ingraham-Lopresto B, Ivy E, Woody G. Hospital-based peer counseling reduces 30 day readmission of alcohol abusing medical inpatient. To be presented at: The 46th Annual American Society of Addiction Medicine Conference; 2015 Apr 23-26; Austin, TX.

Satti SR, Traylor K, Anzilotti K. Incidence of dissection and vasospasm related to distal embolic protection devices during elective carotid artery stenting: 5 year retrospective review. Poster presented at: International Stroke Conference 2015; 2015 Feb 11-13; Nashville, TN.

Vest M, Kolm P, Bowen J, Shapiro M, McGraw P, Halbert J, Trabulsi J, Lennon-Edwards J, Jurkovitz C. Energy balance & outcomes of obese, mechanically ventilated patients in ICU. Poster presented at: DE-CTR ACCEL 2015 Annual Meeting; 2015 Feb 18-20; Charleston, SC.

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. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. To subscribe to Collaborations, please send an e-mail with “Subscribe to Collaborations” in the subject line.