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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.

Improving Risk Stratification for Acute Heart Failure
Building and Testing a Machine-learning Platform for Personalized, Accurate, Real-time Risk Prediction


Investigators: Dana R Sax (Oakland), Jamal S Rana (Oakland), Dustin G Mark (Oakland), Dustin W Ballard (San Rafael), Vincent Liu (DOR), Mary E Reed (DOR) and the KP CREST Network 

In this project, we leverage the power of innovative machine learning approaches and the data available in our  comprehensive electronic health record to develop a highly accurate acute heart failure ED risk stratification tool. Our short-term goal is to implement this tool for bedside, real-time decision support to make better informed hospitalization decisions for ED patients with heart failure. We will identify multilevel barriers and facilitators to dissemination and
implementation, develop tailored implementation strategies, and conduct a multi-center trial to evaluate its implementation. Our long-term goal is to develop a scalable real-time clinical decision support process and systemic implementation strategy for other disease processes.

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Drinking Water at Home
"Cold Drink Heart" 

Characterizing Patients with Cold Drink-triggered Atrial Fibrillation: A Survey Study

Investigators: David R Vinson (Sacramento), Adina Rauchwerger (DOR), Jennifer Zhang (DOR) and the KP CREST Network


Atrial fibrillation (AF) is the most treated cardiac arrhythmia and is associated with an increased risk for heart failure, stroke, myocardial infarction, chronic kidney disease, dementia, and death. Cold drink or food-triggered AF was first reported in the literature 30 years ago, but little progress has been made in understanding this association. We are conducting a patient survey study to characterize patients who have experienced "Cold Drink Heart." Although this study is currently underway, it is evident that avoidance of known AF triggers can help to reduce or even eliminate recurrent episodes.

Improving management of emergency department patients with unexplained syncope: prospective validation of the Canadian Syncope Risk Score

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

Syncope, defined as a temporary loss of consciousness and muscle tone with complete, spontaneous recovery, ​accounts for approximately 1% of all ED visits across the US. A small percentage of unexplained syncope cases are the result of a much more serious underlying issue, such as ventricular arrythmia or pulmonary embolism. This project seeks to build and validate a clinical decision support system in order to better stratify syncope patients by their risk for an adverse event. This tool, which has been embedded in RISTRA (our risk stratification software) is currently undergoing prospective validation at several KPNC faclities.

Covid 19
Post-acute sequelae of COVID (PASC)
Incidence, characteristics and predictors of emergency department visits associated with post-acute sequelae SARS-CoV-2 infection (PASC) among adults

Investigators: Dustin Ballard (San Rafael), Mary Reed (DOR), Margaret Warton (DOR), Jacek Skarbinski (DOR), Edward Durant (Manteca), David Vinson (Sacramento), Marcos Siqueiros (Santa Clara), Sri Madhavi Cholleti (Campbell), Margaret Warton (DOR) and the KP CREST Network


It is well established that COVID-19 symptoms can persist long after initial SARS-CoV-2 infection. The most common of these "post-acute sequelae of COVID" include loss of taste or smell, fatigue, and anxiety and depression. This project seeks to characterize all patients with a PASC-related ED visit and establish associations between specific patient characteristics and a greater likelihood of developing PASC.

COVID-19 in the Emergency Department

A retrospective look at the earliest ED patients in KPNC who tested positive for COVID-19

Investigators: Dale M Cotton (South Sacramento) and the KP CREST Network

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most recent in a series of coronavirus family viruses that can cause severe respiratory illness in humans; in the case of SARS-CoV-2 that disease has been labelled COVID-19. In April of 2020 COVID-19 is widespread across the world, advancing rapidly, and has been labelled a pandemic by the World Health Organization (WHO). Conservative mortality estimates are around 1%, making it an order of magnitude more lethal than seasonal influenza. Existing evidence is crushingly insufficient to address a disease burden as substantial as that posed by COVID-19. Most available data are retrospective descriptive studies from China, with a trickle of information now coming from Italy and the United States. Such narrow data sourcing likely contains numerous biases including ethnic, geographic, social, cultural, governmental, and healthcare effects that may substantially alter characteristics of the disease compared to our KPNC setting. We are in great need of data to understand COVID-19 as it applies to our healthcare providers and patients. The results of this study may provide the best available information to clinically detect and guide ED management for a devastating illness. Because of this, we appreciate the full support from regional leaders in emergency medicine (David Roth), critical care (Greg Marelich), and infectious disease (David Witt and Tara Greenhow).

Validation of a Novel Algorithm for Emergency Department Patients with Possible Acute Coronary Syndromes Following the Transition to a High-Sensitivity Troponin Assay

Investigators: Dustin G. Mark, Jie Huang, Keane K. Lee, Dana R. Sax, Mamata V. Kene, Dustin W. Ballard, David R. Vinson, Mary E. Reed

High sensitivity troponin (hsTn) assays are being increasingly adopted throughout the US, replacing the conventional troponin (cTn) assay. This increase in analytic precision at the patient evaluation stage provides a higher level of diagnostic sensitivity for myocardial injury. An assessment of the predictive accuracy of the KPNC hsTn diagnostic algorithm among ED patients found a 99.8% negative predictive value for 30-day myocardial infarction while identifying 70% of patients for expedited discharge.

Non-traumatic Intracranial Hemorrhage
In-hospital mortality among patients with non-traumatic intracranial hemorrhage: In a hub-and-spoke model of neuroscience care, are outcomes non-inferior following presentation to a spoke versus a hub medical center?


Investigators: Dustin G Mark (Oakland), David R Vinson (Sacramento/Roseville), Chris Sonne (OAK), Mary E Reed (DOR) and the KP CREST Network 

Approximately 63,000 patients are afflicted by non-traumatic ICH annually in the United States, with a 30-day case mortality rate around 30-35%.Practice guidelines recommend that patients with ICH be treated in units with acute neuroscience care experience. Unfortunately, the number of patients with ICH within KPNC greatly exceeds the census capacity of the two KPNC comprehensive stroke and neuroscience centers. This requires careful evaluation via remote consultation in a “hub-and-spoke” model of care delivery to determine which patients might derive the most benefit from care in a dedicated neuroscience unit.     

Renal Stones

Imaging in suspected renal colic: retrospective validation of clinical decision rules to predict uncomplicated ureteral stone

Investigators: Edward J Durant (Manteca/Modesto), David R Vinson (Sacramento/Roseville), Vignesh Arasu (Vallejo), Raymond Bernal (Manteca), Mary E Reed (DOR) and the KP CREST Network

Acute flank pain is a common complaint in the emergency department (ED). Computed tomography (CT) is considered the gold-standard for diagnostic imaging in suspected renal colic. Several researchers have attempted to develop clinical decision rules (CDRs) to predict uncomplicated ureteral stone without the use of CT, but none have been well validated or widely adopted into clinical practice. We seek to remedy this deficit by creating simple CDRs based on recently-published consensus guidelines and to evaluate their performance in a large community-based population. This study will inform the development of a clinical pathway whereby CT overuse can be safely reduced.

Primary Care Pulmonary Embolism Management
Exploring comprehensive primary care clinic-based pulmonary embolism management in terms of prevalence, patient selection, and safety outcomes


Investigators: David R Vinson (Sacramento/Roseville), Erik R Hofmann (South Sacramento), Dustin G Mark (Oakland), Suresh Rangarajan (Oakland), Mary E Reed (DOR) and the KP CREST Network 

The case for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) continues to mount. Guidance in identifying patients who are eligible for ambulatory care is available in the literature and society guidelines. The practice contributes to public health as it improves the healthcare community’s resource stewardship and spares patients the costs, inconveniences, and risks associated with unnecessary hospitalization. This retrospective cohort study aims to understand outpatient PE management conducted entirely in the primary care setting, a practice poorly described in the literature, as we discovered in our narrative review (forthcoming in Perm J). This study will do the following: 1) evaluate the prevalence of primary care clinic home discharge and estimate the annual time trend; 2) describe the patients selected for primary care clinic home discharge and compare them with those discharged home from the ED; and 3) report the incidence of 5-day and 30-day adverse outcomes among those discharged home, either directly from clinic or after ED evaluation.

Cannabinoid Hyperemesis Syndrome
Characterizing patient visits with Cannabinoid Hyperemesis Syndrome (CHS) and examining factors that influence ED length of stay


Investigators: Dale Cotton (South Sacramento), Cynthia Campbell (UCSF), Steven Offerman (South Sacramento), Mary Reed (DOR), Caleb Sunde (South Sacramento) and the KP CREST Network


Marijuana, or cannabis, is by far the most cultivated, used, and abused illicit psychoactive substance in the world. According to the World Health Organization, over 180 million teenagers or adults use cannabis annually. While barriers to use trend downwards, the medical community’s understanding of the risks of cannabis use, especially chronic use, is growing.A less commonly recognized danger of chronic cannabis use is a syndrome of cyclical vomiting and abdominal pain associated with daily or near-daily cannabis use: Cannabinoid Hyperemesis Syndrome (CHS). Despite its observed commonality, the literature and large segments of the medical community remains unaware of this prevalent, costly, and morbidity-associated condition. The case-ascertainment tools we aim to develop to identify patients with CHS can serve as a model for future investigations.

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.

Nurse Taking Notes

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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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.

Chest Cavity
Blood Pressure Exam
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. 

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.

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.
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. 

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