SELECTED PROJECTS

Current

 

Heart Failure 
 
Derivation and testing of a search tool that combines ICD codes and unstructured clinical data to improve accurate case identification of emergency department patients with acute heart failure

 

Investigators: Dana Sax (Oakland), Dustin Mark (Oakland), Jamal Rana (Oakland), Mary Reed (DOR) and the KP CREST Network 

Acute exacerbations cause severe symptoms, defined as acute heart failure (AHF), and contribute to over 1 million emergency department (ED) visits per year.  Research on outcomes, resource utilization, risk stratification and management of AHF patients in the ED is limited both in volume and quality. Through iterative tool refinement with manual chart review of the criteria as the gold standard, we aim to increase the sensitivity, specificity, and positive predictive value of a tool used to accurately identify patients with AHF to over 95%. . Development of a tool that increases accurate case identification of patients with AHF will lead to more reliable estimates of outcomes and resource needs.

American Heart Association

PEDIATRIC APPENDICITIS
 
Electronic health record-based decision support for pediatric acute abdominal pain in emergency care

 

Investigators: Elyse Kharbanda (Health Partners, Minneapolis), Dustin W Ballard (San Rafael), David R Vinson (Sacramento), Mamata Kene (San Leandro), Uli Chettipally (South San Francisco) and the KP CREST Network

 

This five-year project (a) uses EHR technology to deliver patient-specific clinical decision support (CDS) to ED providers at the point of care, (b) assesses the impact of this intervention on the use of diagnostic imaging and clinical outcomes, and (c) assesses the impact of the intervention on the costs of care delivered. This project will be a template for extending EHR-based clinical decision support to other domains of emergency care to ultimately improve a broad range of pediatric acute care outcomes.​ For a FAQ about how doctors use the CDS during implementation click here.

CDS Sustainability
Physician and patient-facing clinical decision support systems (CDSS) via electronic health records

Investigators: Dustin Ballard (San Rafael),  David Vinson (Sacramento), Mary Reed (DOR), and the KP CREST Network

 

Physician and patient-facing clinical decision support systems (CDSS) via electronic health records hold great promise in pushing forward the pace of knowledge translation in the field of medicine. Specifically, evidence supporting the effectiveness of electronic CDSSs is accumulating across a number of condition-specific indications in the Emergency Department (ED) and beyond. Data and perspective are lacking, however, regarding the sustainability of such CDSS-impacted practice change and the characteristics of post-implementation temporal trends. These kinds of data are needed to guide recommendations regarding ideal time duration of CDSS tool promotion with the goal of permanent diffusion of new knowledge and best practices into routine clinical practice.

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Ventricular Tachycardia 
 
The management of stable monomorphic ventricular tachycardia in the community emergency department setting
 
Investigators: Ian McLachlan (San Francisco), Taylor Liu (Santa Clara), James Lin (Santa Clara), Sean Bouvet (Walnut Creek), David Vinson (Sacramento), Mary Reed (DOR) and the KP CREST Network
 
Monomorphic ventricular tachycardia (VT) is most often a precursor to life-threatening ventricular fibrillation and cardiac arrest. A small minority of patients with VT, however, present to the emergency department (ED) alert and oriented, with normal blood pressures. “Stable VT” may be amendable to pharmacological treatment, but because it’s is uncommon, few studies have compared treatments. In this retrospective study, we aim to describe patient selection, treatment variation, VT termination rates, and major side effects in VT management.
Kidney Injury 
 
Evaluating the incidence of contrast associated acute kidney injury in emergency department patients

 

Investigators: Mamata Kene (San Leandro), Vignesh Arasu (Vallejo), Ajit Mahapatra (Santa Clara), Mary Reed (DOR), and the KP CREST Network

Recent Studies of acute kidney injury (AKI) after intravenous contrast-enhanced computed tomography (CT) suggest that prior observational studies overestimate the incidence of contrast-associated AKI, and cast doubt on whether intravenous contrast is even associated with AKI. We aim to evaluate AKI incidence in a retrospective observational study among all adult ED patients with chronic kidney disease stage 3-5 undergoing CT with or without intravenous contrast.

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Whole Health Insider

Pulmonary Embolism 
 
Recognition of Outpatient Pulmonary Embolism (the ROPE study)
 
Investigators: Ian McLachlan (San Francisco), David Vinson (Sacramento), Mary Reed (DOR), Dustin Ballard (San Rafael), and the KP CREST Network
This retrospective study aims to (1) quantify the prevalence of unrecognized PE in the 14 days prior to diagnostic confirmation, (2) compare the rates of risk factor documentation between encounters with a missed diagnosis (the Unrecognized Group) and those with prompt referral to the ED for definitive diagnostic or therapeutic care (the Expedited Group), and (3) compare the groups with respect to their PE Severity Index scores, ED dispositions, and 30-day major outcomes.
ATRIAL FIBRILLATION AND FLUTTER
 
Amiodarone and procainamide for the cardioversion of atrial fibrillation/flutter: The Pharm CAFÉ Study
 
Investigators: David R Vinson (Sacramento), Dustin W Ballard (San Rafael), Aarom Rome and Nelya Lugovskaya (UC Davis), Matt Stevenson (Loma Linda), and the KP CREST Network
 
This comparative effectiveness study will yield important information to help guide emergency providers in the selection of pharmacological agents for the cardioversion of AF/F.
ATRIAL FIBRILLATION/FLUTTER
 
The management of ED patients with atrial fibrillation and flutter: a multi-center prospective outcomes study

Investigators: David R Vinson (Sacramento), the KP CREST Network, Jie Huang (DOR), Patricia Ramos (KP Portland), David Glaser (KP Denver)

 

This prospective cohort study profiled the characteristics of ED patients with non-valvular AF in community settings, described the variation in management across EDs, and correlated patient and management variables with utilization, procedures, and complications. Enrollment of 2,700 patients at 9 centers has been completed. Analysis is underway.

Chest Pain (STEWARD)
 
KP-specific Cardiac History and Risk Summaries: KPNC Standardizing Emergency Work-ups Around Risk Data (STEWARD) Chest Pain Project - Phase 1

 

Investigators: Dustin G Mark (Oakland), Mary Reed (DOR), Dustin Ballard (San Rafael), Mamata Kene (San Leandro) and the KP CREST Network

 

Chest pain is the second leading reason for emergency department (ED) visits in the United States and accounts for over 45,000 KPNC ED visits annually. Our project will take advantage of the large internal patient population and rich electronic data (both patient history and real-time measures) to offer KPNC clinicians more accurate risk estimates for patients with chest pain. Using a retrospective cohort (2013-2015), we propose to examine KPNC ED chest pain care and outcomes to determine KPNC-specific risk estimates for MACE among patients with chest pain presenting to KPNC EDs.

STEWARD Heart Failure
 
KP-specific heart failure risk prediction: KPNC Standardizing Emergency Work-ups Around Risk Data (STEWARD) Heart Failure Project

Investigators: Dana Sax (Oakland), Mary Reed (DOR), and the KP CREST Network

 

There are over one million ED visits across the U.S. each year for acute heart failure (AHF), with an average admission rate of 84%. EDs play a major role in the care of AHF patients through symptom management, coordination of care, and risk stratification to identify sicker patients needing admission. Within KPNC, patients make over 15,000 annual ED visits for AHF, and there is significant inter-facility variation in rates of admission, 7- and 30-day re-admission, hospital length of stay, and patient outcomes. A clinical decision support tool to help predict AHF disease severity, employing accurate KPNC-specific risk estimates, would allow for more informed recommendations around venues and intensity of care customized to the KPNC setting. 

HEART FAILURE
 
Relationship between an integrated care system and safe outpatient management of emergency department patients with acute heart failure
 
Investigators: Dana Kindermann Sax (Oakland), Dustin Mark (Oakland), Alan Go (DOR) and the KP CREST Network
 
This retrospective study will test the hypothesis that certain system-level factors within integrated delivery systems are associated with safe outpatient management after an ED visit for acute heart failure.
RISTRiage
 
Standardizing ER triage across KPNC emergency departments: understanding the problem of under-triage and its implications on patient safety

Investigators: Dana Sax (Oakland), Mary Reed (DOR), and the KP CREST Network

 

The most commonly used ED triage system in the United States, and throughout KPNC, is the Emergency Severity Index. Unfortunately, studies have shown that triage assignments are often subjective and have poor inter-rater reliability. Mis-triage, both under- and over-triage, leads to delays in care and may introduce bias into providers’ evaluations, with serious potential patient safety concerns.  For Phase I of this initiative we are currently proposing to assess the frequency of under-triage and its potential patient safety implications across all 21 KPNC EDs.  We also aim to identify factors that predict this under-recognition of patient acuity or resource needs.

Clinical Decision Support for AFF

Improving Stroke Prevention for High-risk Atrial Fibrillation

by Discharge Redesign Using Electronic Clinical Decision Support

Investigators: David Vinson (Sacramento), Mary Reed (DOR), Dustin Mark (Oakland), Dustin Ballard (San Rafael), Uli Chettipally, Bory Kea, Alan Go, and the KP CREST Network

Recent KPNC internal data demonstrate that 60% of anticoagulation-naive patients with non-valvular atrial fibrillation or flutter (AF/FL) at high risk of stroke who seek emergency department (ED) rhythm-related care fail to receive thromboprophylaxis on discharge, a practice paralleled in the inpatient setting.Contributing to this missed opportunity is physicians’ underestimation of stroke risk and overestimation of bleeding risk. Using the CREST Network’s innovative web-based electronic CDSS (called RISTRA), we will redesign the AF/FL ED discharge process. 

The KP CREST Network in Northern California is not alone in doing emergency medicine research in Kaiser Permanente. Clinical researchers in KP Southern California are also active. We in CREST collaborate with our SoCAL counterparts on studies and also team up to produce quarterly reports that highlight recent projects and publications from both halves of the Golden State. You can read the latest report here.

© 2013 CREST Network