Using Agile Science for Rapid Innovation and Implementation of a New Care Model.

As industry consolidation leads to a growing number of large new healthcare delivery networks, patients and their clinicians are losing the important human-centric and relationship-based nature of medical care. The leadership of Hackensack Meridian Health (HMH), a New Jersey-based network of hospitals, research center, and medical school, made an organizational commitment to reverse such loss and restore the social nature of medicine. To attain that goal, HMH engaged both clinicians and administrators to confirm the demand for change, foster a collaborative culture design, and address the unique nature of the individual components in the HMH network. Efforts to transform the HMH care delivery model illustrate the effectiveness of Agile science and its problem-solving methods.

Nurse perceptions of a nurse family liaison implemented during the COVID-19 pandemic: A qualitative thematic analysis.

OBJECTIVE: Stress among family members of hospitalised intensive care unit patients may be amplified in the context of a global pandemic and strict visitor restrictions. A nurse family liaison role in the COVID-19 units was implemented to serve as a connection between the care team and a designated family member. Our objective was to describe the experience of a nurse family liaison role implemented during the COVID-19 pandemic from the perspective of nurses who functioned in the liaison role and intensive care nurses who worked with the liaisons. RESEARCH METHOD/DESIGN: This was a qualitative study using thematic analysis involving a one-time semi-structured interview. A convenience sample of nurses were invited to participate. The analytic approach involved (1) becoming familiar with the data; (2) finding meaning in the data; (3) organising meaningful statements into patterns to generate themes. SETTING/PARTICIPANTS: Nurses who functioned in the liaison role and intensive care nurses who worked with the liaisons in an adult academic health center in the Midwest United States. MAIN OUTCOME MEASURE: To describe the psychosocial experience of nurse family liaison role implementation. FINDINGS: The sample (n = 11) mean age was 36 years (range 26-49) and the majority were female (n = 10; 90%), White/non-Hispanic (n = 11; 100%), Bachelor prepared (n = 10; 90%), and had an average of 10 years of experience as a nurse (range 4-25). The major themes identified by participants were living in a pandemic, establishing the role and workflow and experiencing human connection. CONCLUSION: Hospital organisations should consider how they can provide family-centred care, specifically within the context of a global crisis such as a pandemic. Participant descriptions of the role indicate that liaison implementation alleviated nurse moral distress and fostered development of close family connections. Findings can help inform implementation of similar roles in hospital settings.

Major Surgery and Long Term Cognitive Outcomes: The Effect of Postoperative Delirium on Dementia in the Year Following Discharge.

BACKGROUND: Delirium is among the most common complications following major surgery. Delirium following medical illness is associated with the development of chronic cognitive decline. The objective of this study was to determine the association of postoperative delirium with dementia in the year following surgery. MATERIALS AND METHODS: This was a retrospective cohort study in a large health network (January 2013 to December 2019). All patients over age 50 undergoing surgery requiring an inpatient stay were included. Our main exposure was an episode of delirium. The primary outcome was a new dementia diagnosis in the 1 y following discharge. Secondary outcomes included hospital length of stay, non-home discharge destination, mortality and rehospitalizations in 1 y. RESULTS: There were 39,665 patients included, with a median age of 66. There were 4156 of 39,665 emergencies (10.5%). Specialties were general surgery (12,285/39,665, 31%) and orthopedics (11,503/39,665, 29%). There were 3327 (8.4%) patients with delirium. Delirious patients were older and were more likely to have comorbid conditions and undergone complex procedures. There were 1353 of 39,665 (3.5%) patients who developed dementia in the year following their surgery; 4930 of 39,665 (12.4%) who died; and 8200 of 39,665 (20.7%) who were readmitted. Delirium was associated with a new dementia diagnosis after adjusting for baseline characteristics (Odds ratio [OR] 13.9; 95% CI, 12.2-15.7). Similarly, delirium was also associated with 1 y mortality (OR 3.1; 95% CI 2.9-3.4) and readmission (OR 1.9, 95% CI 1.7-2.0). CONCLUSIONS: Postoperative delirium is the strongest factor associated with development of dementia in the year following a major operation. Strategies to prevent, identify, and treat delirium in the postoperative setting may improve long-term cognitive recovery.

The Indiana Learning Health System Initiative: Early experience developing a collaborative, regional learning health system.

INTRODUCTION: Learning health systems (LHSs) are usually created and maintained by single institutions or healthcare systems. The Indiana Learning Health System Initiative (ILHSI) is a new multi-institutional, collaborative regional LHS initiative led by the Regenstrief Institute (RI) and developed in partnership with five additional organizations: two Indiana-based health systems, two schools at Indiana University, and our state-wide health information exchange. We report our experiences and lessons learned during the initial 2-year phase of developing and implementing the ILHSI. METHODS: The initial goals of the ILHSI were to instantiate the concept, establish partnerships, and perform LHS pilot projects to inform expansion. We established shared governance and technical capabilities, conducted a literature review-based and regional environmental scan, and convened key stakeholders to iteratively identify focus areas, and select and implement six initial joint projects. RESULTS: The ILHSI successfully collaborated with its partner organizations to establish a foundational governance structure, set goals and strategies, and prioritize projects and training activities. We developed and deployed strategies to effectively use health system and regional HIE infrastructure and minimize information silos, a frequent challenge for multi-organizational LHSs. Successful projects were diverse and included deploying a Fast Healthcare Interoperability Standards (FHIR)-based tool across emergency departments state-wide, analyzing free-text elements of cross-hospital surveys, and developing models to provide clinical decision support based on clinical and social determinants of health. We also experienced organizational challenges, including changes in key leadership personnel and varying levels of engagement with health system partners, which impacted initial ILHSI efforts and structures. Reflecting on these early experiences, we identified lessons learned and next steps. CONCLUSIONS: Multi-organizational LHSs can be challenging to develop but present the opportunity to leverage learning across multiple organizations and systems to benefit the general population. Attention to governance decisions, shared goal setting and monitoring, and careful selection of projects are important for early success.

Development and Validation of a 30-Day In-hospital Mortality Model Among Seriously Ill Transferred Patients: a Retrospective Cohort Study.

BACKGROUND: Predicting the risk of in-hospital mortality on admission is challenging but essential for risk stratification of patient outcomes and designing an appropriate plan-of-care, especially among transferred patients. OBJECTIVE: Develop a model that uses administrative and clinical data within 24 h of transfer to predict 30-day in-hospital mortality at an Academic Health Center (AHC). DESIGN: Retrospective cohort study. We used 30 putative variables in a multiple logistic regression model in the full data set (n = 10,389) to identify 20 candidate variables obtained from the electronic medical record (EMR) within 24 h of admission that were associated with 30-day in-hospital mortality (p < 0.05). These 20 variables were tested using multiple logistic regression and area under the curve (AUC)-receiver operating characteristics (ROC) analysis to identify an optimal risk threshold score in a randomly split derivation sample (n = 5194) which was then examined in the validation sample (n = 5195). PARTICIPANTS: Ten thousand three hundred eighty-nine patients greater than 18 years transferred to the Indiana University (IU)-Adult Academic Health Center (AHC) between 1/1/2016 and 12/31/2017. MAIN MEASURES: Sensitivity, specificity, positive predictive value, C-statistic, and risk threshold score of the model. KEY RESULTS: The final model was strongly discriminative (C-statistic = 0.90) and had a good fit (Hosmer-Lemeshow goodness-of-fit test [X2 (8) =6.26, p = 0.62]). The positive predictive value for 30-day in-hospital death was 68%; AUC-ROC was 0.90 (95% confidence interval 0.89-0.92, p < 0.0001). We identified a risk threshold score of -2.19 that had a maximum sensitivity (79.87%) and specificity (85.24%) in the derivation and validation sample (sensitivity: 75.00%, specificity: 85.71%). In the validation sample, 34.40% (354/1029) of the patients above this threshold died compared to only 2.83% (118/4166) deaths below this threshold. CONCLUSION: This model can use EMR and administrative data within 24 h of transfer to predict the risk of 30-day in-hospital mortality with reasonable accuracy among seriously ill transferred patients.

Using a Modified Surprise Question as a Tool to Improve Primary Palliative Care in a Neurocritical Care Unit.

BACKGROUND: Specialty palliative care is a limited resource. The surprise question ("Would you be surprised if this patient died within the next 12 months?") is a screening tool for clinicians to identify people nearing the end of life. The researchers used a modified surprise question (MSQ) to improve primary palliative care in a neurocritical care unit. METHODS: A palliative care physician attended interdisciplinary rounds up to three days a week and asked the primary neurocritical care team, for each patient admitted in the previous 24 hours, the MSQ: "Would you be surprised if this patient died during this hospital stay?" If the response was "No," the unit social worker identified the patient's surrogate decision maker (SDM), and the primary team was encouraged to conduct a goals of care (GOC) conversation. The frequency of SDM documentation, occurrence and timing of GOC conversations, and palliative care and hospice consultations were measured for the baseline six months before the intervention, and six months after. RESULTS: Among 350 patients admitted to the neurocritical care unit during the study, the age, gender, prehospitalization presence of advance directives, and mortality were comparable between the baseline (n = 173) and intervention (n = 177) periods. Compared to the baseline period, there was a higher frequency during the intervention period of documentation of SDM (31.8% vs. 54.2%, p = 0.00002), all GOC conversations (35.3% vs. 53.1%, p = 0.008), GOC conversations conducted by the primary team (27.2% vs. 47.5%, p = 0.00009), palliative care consultations (11.6% vs. 23.2%, p = 0.004), and hospice consultations (2.3% vs. 9.6%, p = 0.004). CONCLUSION: The MSQ can be used as a tool to identify the risk of mortality, facilitate palliative care delivered by the primary team, and improve end-of-life care.

Changing the culture of urine culturing: Utilizing Agile Implementation to improve diagnostic stewardship in the ICU.

Over diagnosis of catheter-associated urinary tract infection (CAUTI) contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridiodes difficile infections, as well as a false elevation in CAUTI rates. Utilizing agile implementation to implement a urine culture algorithm achieved statistically significant reduction in CAUTI rates in a critical care unit resulting in sustainment and spread throughout the system.

Utilizing a real-time discussion approach to improve the appropriateness of Clostridioides difficile testing and the potential unintended consequences of this strategy.

We report electronic medical record interventions to reduce Clostridioides difficile testing risk 'alert fatigue.' We used a behavioral approach to diagnostic stewardship and observed a decrease in the number of tests ordered of ~4.5 per month (P < .0001). Although the number of inappropriate tests decreased during the study period, delayed testing increased.

Using the agile implementation model to reduce central line-associated bloodstream infections.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are among the most common hospital-acquired infections and can lead to increased patient morbidity and mortality rates. Implementation of practice guidelines and recommended prevention bundles has historically been suboptimal, suggesting that improvements in implementation methods could further reductions in CLABSI rates. In this article, we describe the agile implementation methodology and present details of how it was successfully used to reduce CLABSI. METHODS: We conducted an observational study of patients with central line catheters at 2 adult tertiary care hospitals in Indianapolis from January 2015 to June 2017. RESULTS: The intervention successfully reduced the CLABSI rate from 1.76 infections per 1,000 central line days to 1.24 (rate ratio = 0.70; P = .011). We also observed reductions in the rates of Clostridium difficile and surgical site infections, whereas catheter-associated urinary tract infections remained stable. CONCLUSIONS: Using the AI model, we were able to successfully implement evidence-based practices to reduce the rate of CLABSIs at our facility.

Assessing patient risk of central line-associated bacteremia via machine learning.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) contribute to increased morbidity, length of hospital stay, and cost. Despite progress in understanding the risk factors, there remains a need to accurately predict the risk of CLABSIs and, in real time, prevent them from occurring. METHODS: A predictive model was developed using retrospective data from a large academic healthcare system. Models were developed with machine learning via construction of random forests using validated input variables. RESULTS: Fifteen variables accounted for the most significant effect on CLABSI prediction based on a retrospective study of 70,218 unique patient encounters between January 1, 2013, and May 31, 2016. The area under the receiver operating characteristic curve for the best-performing model was 0.82 in production. DISCUSSION: This model has multiple applications for resource allocation for CLABSI prevention, including serving as a tool to target patients at highest risk for potentially cost-effective but otherwise time-limited interventions. CONCLUSIONS: Machine learning can be used to develop accurate models to predict the risk of CLABSI in real time prior to the development of infection.

Etoposide as a single agent in the treatment of mycosis fungoides: A retrospective analysis.

Several chemotherapy agents have shown efficacy in the treatment of mycosis fungoides (MF). In the literature, there is limited data on the use of single agent etoposide for MF. We aimed to retrospectively review our experience with single agent etoposide in the treatment of advanced-stage or refractory early-stage MF with focus on analyzing its efficacy and safety. We included 13 MF patients who were treated with single agent etoposide. Patients were identified through the Cutaneous T Cell Lymphoma Database of Indiana University that involves patients treated from 2006 to 2016. Overall nine patients (69%) responded to treatment. No complete response was identified. Median time to response was 12.5 weeks (range: 6-25.4). Median duration of response was 43 weeks (range: 5-60) and median time to treatment failure was 31.3 weeks (range: 12.4-230). Hematological toxicity was observed in eight patients including two patients with grade 4 neutropenia and/or lymphopenia leading to sepsis. Higher doses of etoposide were significantly correlated with higher grades of anemia, neutropenia or lymphopenia (p < .05). Our study demonstrates that etoposide is an effective treatment for MF and may be considered in selected patients with progressive MF who have failed other treatments.

Evaluation of interprofessional relational coordination and patients' perception of care in outpatient oncology teams.

This pilot study was designed to measure teamwork and the relationship of teamwork to patient perceptions of care among 63 members of 12 oncology teams at a Cancer Centre in the Midwest. Lack of teamwork in cancer care can result in serious clinical errors, fragmentation of care, and poor quality of care. Many oncology team members, highly skilled in clinical care, are not trained to work effectively as members of a care team. The research team administered the Relational Coordination survey to core oncology team members-medical oncologists, nurse coordinators, and clinical secretaries-to measure seven dimensions of team skills (four relating to communication [frequency, timeliness, accuracy, and problem solving] and three relating to relationship [shared goals, shared knowledge, and mutual respect]) averaged to create a Relational Coordination Index. The results indicated that among the team member roles, nurse coordinator relational coordination indices were the strongest and most positively correlated with patient perception of care. Statistically significant correlations were intra-nurse coordinator relational coordination indices and two patient perception of care factors (information and education and patient's preferences). All other nurse coordinator intra-role as well as inter-role correlations were also positively correlated, although not statistically significant.

The Indiana University Center for Healthcare Innovation and Implementation Science: Bridging healthcare research and delivery to build a learning healthcare system.

In the United States, it is estimated that 75,000 deaths every year could be averted if the healthcare system implemented high quality care more effectively and efficiently. Patient harm in the hospital occurs as a consequence of inadequate procedures, medications and other therapies, nosocomial infections, diagnostic evaluations and patient falls. Implementation science, a new emerging field in healthcare, is the development and study of methods and tools aimed at enhancing the implementation of new discoveries and evidence into daily healthcare delivery. The Indiana University Center for Healthcare Innovation and Implementation Science (IU-CHIIS) was launched in September 2013 with the mission to use implementation science and innovation to produce great-quality, patient-centered and cost-efficient healthcare delivery solutions for the United States of America. Within the first 24 months of its initiation, the IU-CHIIS successfully scaled up an evidence-based collaborative care model for people with dementia and/or depression, successfully expanded the Accountable Care Unit model positively impacting the efficiency and quality of care, created the first Certificate in Innovation and Implementation Science in the US and secured funding from National Institutes of Health to investigate innovations in dementia care. This article summarizes the establishment of the IU-CHIIS, its impact and outcomes and the lessons learned during the journey.

Systematic review of interdisciplinary interventions in nursing homes.

BACKGROUND: The role of interdisciplinary interventions in the nursing home (NH) setting remains unclear. We conducted a systematic evidence review to study the benefits of interdisciplinary interventions on outcomes of NH residents. We also examined the interdisciplinary features of successful trials, including those that used formal teams. DATA SOURCES: Medline was searched from January 1990 to August 2011. Search terms included residential facilities, long term care, clinical trial, epidemiologic studies, epidemiologic research design, comparative study, evaluation studies, meta-analysis and guideline. STUDY SELECTION: We included randomized controlled trials (RCTs) evaluating the efficacy of interdisciplinary interventions conducted in the NH setting. MEASUREMENTS: We used the Cochrane Collaboration tools to appraise each RCT, and an RCT was considered positive if its selected intervention had a significant positive effect on the primary outcome regardless of its effect on any secondary outcome. We also extracted data from each trial regarding the participating disciplines; for trials that used teams, we studied the reporting of various team elements, including leadership, communication, coordination, and conflict resolution. RESULTS: We identified 27 RCTs: 7 had no statistically significant effect on the targeted primary outcome, 2 had a statistically negative effect, and 18 demonstrated a statistically positive effect. Participation of residents' own primary physicians (all 6 trials were positive) and/or a pharmacist (all 4 trials were positive) in the intervention were common elements of successful trials. For interventions that used formal team meetings, presence of communication and coordination among team members were the most commonly observed elements. CONCLUSION: Overall interdisciplinary interventions had a positive impact on resident outcomes in the NH setting. Participation of the residents' primary physician and/or a pharmacist in the intervention, as well as team communication and coordination, were consistent features of successful interventions.

Connecting research discovery with care delivery in dementia: the development of the Indianapolis Discovery Network for Dementia.

BACKGROUND: The US Institute of Medicine has recommended an integrated, locally sensitive collaboration among the various members of the community, health care systems, and research organizations to improve dementia care and dementia research. METHODS: Using complex adaptive system theory and reflective adaptive process, we developed a professional network called the "Indianapolis Discovery Network for Dementia" (IDND). The IDND facilitates effective and sustainable interactions among a local and diverse group of dementia researchers, clinical providers, and community advocates interested in improving care for dementia patients in Indianapolis, Indiana. RESULTS: The IDND was established in February 2006 and now includes more than 250 members from more than 30 local (central Indiana) organizations representing 20 disciplines. The network uses two types of communication to connect its members. The first is a 2-hour face-to-face bimonthly meeting open to all members. The second is a web-based resource center (http://www.indydiscoverynetwork.org ). To date, the network has: (1) accomplished the development of a network website with an annual average of 12,711 hits per day; (2) produced clinical tools such as the Healthy Aging Brain Care Monitor and the Anticholinergic Cognitive Burden Scale; (3) translated and implemented the collaborative dementia care model into two local health care systems; (4) created web-based tracking software, the Enhanced Medical Record for Aging Brain Care (eMR-ABC), to support care coordination for patients with dementia; (5) received more than USD$24 million in funding for members for dementia-related research studies; and (6) adopted a new group-based problem-solving process called the "IDND consultancy round." CONCLUSION: A local interdisciplinary "think-tank" network focused on dementia that promotes collaboration in research projects, educational initiatives, and quality improvement efforts that meet the local research, clinical, and community needs relevant to dementia care has been built.

Is the blood-brain barrier relevant in metastatic germ cell tumor?

PURPOSE: Germ cell tumors are uniquely chemosensitive and curable, even with advanced metastatic disease. Central nervous system recurrence can terminate a complete remission in other chemosensitive tumors, such as small cell lung cancer, because of the blood-brain barrier (BBB). We propose to document that the BBB is also relevant in germ cell tumors despite their dramatic chemosensitivity. METHODS AND MATERIALS: We present five cases illustrating the concept of the BBB in patients with metastatic testicular cancer treated with chemotherapy. RESULTS: In our large series of patients with metastatic testicular cancer treated with chemotherapy, we identified 5 unique patients. These patients were rendered free of disease only to experience relapse in the brain alone. This included 1 patient who initially had good-risk metastatic disease by means of the International Germ Cell Collaborative Group staging system at the onset of chemotherapy. CONCLUSIONS: The BBB is relevant in patients with metastatic testicular cancer.