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.
Febrile Infant (STEWARD)
A retrospective look at testing utilization and outcomes in febrile infants and subsequent development of novel clinical decision support tools
Investigators: Dustin W Ballard (San Rafael), Tara Greenhow (San Francisco), David R Vinson (Sacramento/Roseville), Dustin G Mark (Oakland), Mamata V Kene (San Leandro), Mary E Reed (DOR), Beverly Young (Roseville), Adam L Sharp (KPSC) and the KP CREST Network
A visit to the emergency department (ED) with an ill infant can be extremely stressful for providers and parents. Many ED providers are uncertain of the best approach to the diagnostic evaluation of the febrile infant. This uncertainty stems from numerous existing risk stratification protocols and varying understandings of, and compliance with, existing guidelines. Consequently, some infants undergo unnecessary invasive procedures to rule out serious bacterial infection and herpes simplex virus (blood cultures, lumbar punctures [LP], chest x-rays). The aims of this study are to 1) define retrospective incidence rates of testing utilization and outcomes in febrile infants 7-90 days, 2) prospectively collect data and promote American Academy of Pediatrics (AAP) and KPNC guidelines through clinical decision support tools embedded in the electronic health record (e.g., RISTRA/Scaffold), and 3) implement new clinical decision support based on forthcoming 2020 AAP guidelines including shared decision-making components for LP/hospitalization/herpes simplex virus risk.
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.
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
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.
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.
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.
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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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.
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.
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.