A system-wide extracorporeal membrane oxygenation quality collaborative improves patient outcomes.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) use in adult patient populations has grown rapidly with wide variation in practices and outcomes. We evaluated the impact on patient outcomes, resource use, and costs of an initiative to coordinate and standardize best practices across ECMO programs within a large integrated health care system. METHODS: The ECMO Collaborative Project brought clinicians and service-line leaders from 4 programs within a single health care system together with operational subject matter experts tasked with developing and implementing standardized guidelines, order sets, and an internal database to support an automated quarterly report card. Patient outcomes, resource use, and financial measures were compared for the 16 months before (January 2017 to April 2018; "precollaborative," n = 185) versus the 14 months after (November 2018 to December 2019, "postcollaborative," n = 243) a 6-month implementation and blanking period. Subset analyses were performed for venoarterial ECMO, venovenous ECMO, and extracorporeal cardiopulmonary resuscitation. RESULTS: Survival to discharge/transfer increased significantly (in-hospital mortality hazard ratio, 0.75; 95% confidence interval [95% CI], 0.58-0.99) for the postcollaborative versus the precollaborative period (107/185, 57.8% vs 113/243, 46.5%, P = .03), predominantly due to improvement among patients receiving venoarterial ECMO (hazard ratio, 0.61; 95% CI, 0.41-0.91). The percentage of patients successfully weaned from ECMO increased from 58.9% (109/185) to 70% (170/243), P = .02. Complication rates decreased by 40% (incidence rate ratio, 0.60; 95% CI, 0.49-0.72). No significant changes were observed in ECMO duration, intensive care unit or hospital length of stay, or cost-per-case; payment-per-case and contribution-margin-per-case both decreased significantly. CONCLUSIONS: The ECMO Collaborative Project improved survival to discharge/transfer, weaning rates and complications, without additional costs, through coordination and standardization across ECMO programs within a health care system.

Diagnostic Accuracy in Primary Care E-Visits: Evaluation of a Large Integrated Health Care Delivery System's Experience.

OBJECTIVE: To compare diagnostic accuracy between primary care E-Visit and face-to-face (F2F) encounters for low-acuity illnesses. PATIENTS AND METHODS: This cross-sectional retrospective analysis of electronic health records in a large not-for-profit integrated delivery system included patients covered by the health care system's employee health plan with an established affiliated physician-patient relationship and an F2F encounter in the past 12 months who had an E-Visit (n=490) or an F2F (n=2201) primary care encounter for a low-acuity illness from July 1, 2015, through December 22, 2016. Patients with a related follow-up visit within 10 days resulting in a revised diagnosis, as determined by 2 physician reviewers, were compared (1) including only the first encounter for each patient and (2) including all encounters more than 10 days apart for included patients. RESULTS: In both analyses, a follow-up visit occurred within 10 days more than 40% of the time in both groups. However, follow-up visits related to the initial diagnosis occurred only 9% to 12% of the time. Only 2.1% to 2.4% of initial diagnoses were identified by both physician reviewers as revised, whereas 3.8% to 5.5% were so identified by at least 1 reviewer. The only significant difference observed between the E-Visit and F2F groups was in the rate of related follow-up visits when only each patient's first encounter was considered, which was higher for E-Visits (12% vs 9%; P=.04). CONCLUSION: Diagnostic accuracy for low-acuity illnesses in this population was equivalent between E-Visit and F2F encounters.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed. STUDY DESIGN: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. DATA COLLECTION: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.