Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis.

OBJECTIVE: The objective of this study was to assess the clinical and financial impact of a quality improvement project that utilized a modified Early Warning Score (mEWS)-based clinical decision support intervention targeting early recognition of sepsis decompensation. MATERIALS AND METHODS: We conducted a retrospective, interrupted time series study on all adult patients who received a diagnosis of sepsis and were exposed to an acute care floor with the intervention. Primary outcomes (total direct cost, length of stay [LOS], and mortality) were aggregated for each study month for the post-intervention period (March 1, 2016-February 28, 2017, n = 2118 visits) and compared to the pre-intervention period (November 1, 2014-October 31, 2015, n = 1546 visits). RESULTS: The intervention was associated with a decrease in median total direct cost and hospital LOS by 23% (P = .047) and .63 days (P = .059), respectively. There was no significant change in mortality. DISCUSSION: The implementation of an mEWS-based clinical decision support system in eight acute care floors at an academic medical center was associated with reduced total direct cost and LOS for patients hospitalized with sepsis. This was seen without an associated increase in intensive care unit utilization or broad-spectrum antibiotic use. CONCLUSION: An automated sepsis decompensation detection system has the potential to improve clinical and financial outcomes such as LOS and total direct cost. Further evaluation is needed to validate generalizability and to understand the relative importance of individual elements of the intervention.

Supratherapeutic anti-factor Xa levels in patients receiving prophylactic doses of enoxaparin: A case series.

INTRODUCTION: Enoxaparin prophylaxis prevents venous thromboembolism in surgical patients. Real time anti-Factor Xa monitoring for surgical patients on enoxaparin prophylaxis is increasingly common. PRESENTATION OF CASES: We report on three cancer patients with therapeutic or supratherapeutic anti-Factor Xa levels while on prophylactic doses of enoxaparin after surgical procedures. In all cases, elevated anti-Factor Xa levels were the result of blood specimens being removed from a heparinized chemoport. DISCUSSION: This case series highlights the importance of peripheral venipuncture or appropriate blood wasting from central access sites for anti-Factor Xa levels. CONCLUSION: Inappropriately drawn anti-Factor Xa levels may contribute to prophylaxis interruption or unnecessary workup for renal or liver failure.

Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality.

IMPORTANCE: Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE: To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS: Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES: Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES: Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS: From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02). CONCLUSIONS AND RELEVANCE: Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.

Withholding anticoagulation following a single negative whole-leg ultrasound in patients at high pretest probability for deep vein thrombosis.

Prompt, accurate diagnosis of deep vein thrombosis (DVT) is essential. A single, whole-leg ultrasound (whole-leg US) has been used to exclude DVT, but limited data exist for patients with high pretest probability (PTP) for DVT. This diagnostic management study tested the rate of venous thromboembolism (VTE) in patients with a PTP of "DVT likely" per the simplified Wells score when anticoagulation is withheld based on a single, negative whole-leg US. Consecutive patients presenting during coordinator shifts with a PTP of DVT likely were enrolled. Anticoagulation was withheld after a single, negative whole-leg US. The outcome was objectively confirmed VTE in 3 months. All 167 patients completed the follow-up. A single patient death was adjudicated as possibly caused by VTE, resulting in a VTE rate of 0.60% (95% confidence interval: 0.02%-3.29%). Whole-leg US should be further studied in diagnostic algorithms that utilize PTP scoring and D-dimer testing.

Identification of risk factors associated with critical illness related corticosteroid insufficiency in burn patients.

The goal of this analysis was to characterize risk factors of patients who develop critical illness-related corticosteroid insufficiency (CIRCI) after acute burn injury. This is a retrospective, single-center case-control descriptive study performed at a regional burn unit at an academic medical center. Patients are adults with acute burn injury who developed CIRCI (cases) and sex-, age-, and burn size-matched controls. Cases were compared with controls based on clinical characteristics. Conditional logistic regression analysis was used to establish potential risk factors for cortisol insufficiency. CIRCI was diagnosed in 23 of 1183 patients during the period reviewed (1.9%); 159 controls were matched. CIRCI patients demonstrated significantly greater length of stay (35.1 vs 65.8 days, P ≤ .001), ventilator days (20.5 vs 33.2 days, P ≤ .001), and mortality (2.5% vs 17.4%, P ≤ .001) than controls. Patients with higher Charlson Comorbidity Index scores were more likely to develop cortisol insufficiency (odds ratio 1.58, 95% confidence interval 1.20-2.08), as were patients with inhalation injury (odds ratio 6.46, 95% confidence interval 2.01-20.72). Antibiotics and sedative/hypnotics analyzed by class were not significant. Multivariate conditional logistic regression analysis including Charlson Comorbidity Index and inhalation injury showed significant association of both dependent variables with CIRCI (pseudo-R2 = .32, P ≤ .001). Preexisting comorbidities and inhalation injury provide significant risks for development of CIRCI after acute burn injury. Acute burn patients who develop CIRCI have higher mortality, length of stay, and ventilator days than matched controls.

Pulmonary embolism with unexpected echocardiogram findings.

A 56-year-old woman was evaluated for dyspnea in the emergency department. She had no risk factors for venous thromboembolism except hormone replacement therapy; however, pulmonary embolism was suspected and subsequently confirmed via computed tomographic angiogram. An echocardiogram was conducted to further assess right ventricular function, revealing marked right ventricular enlargement and a mobile mass in the left atrium (initially suspected to be an atrial myxoma). After subsequent embolization to the left axillary artery, thrombolysis was administered, and embolectomy confirmed this to be thrombus. A repeat echocardiogram showed resolution. This case highlights that although echocardiography can be helpful in risk stratification when assessing patients with pulmonary embolism, unexpected findings may be encountered. When clinicians identify multiple clinical findings, Occam's razor suggests that these multiple findings are most likely related.