CREST IN THE PRESS
Division of Research Spotlight
A new Kaiser Permanente CREST Network study shows high success rates for emergency physician gestalt when making an initial prediction about whether a child has appendicitis, especially in low-risk cases. These findings suggest that in low-risk cases, experienced clinicians can follow their intuition and avoid unnecessary abdominal imaging of pediatric patients.
Division of Research Spotlight
Using a simple new clinical tool called the Pediatric Appendicitis Risk Calculator (pARC), Kaiser Permanente emergency doctors were able to accurately gauge the risk of appendicitis in children.The tool was found to perform better than the previously best-performing tool, and allows the possibility to more quantitatively discuss a child's risk of appendicitis.
Division of Research Spotlight
Researcher Mary Reed led a survey study of 1,274 patients in Kaiser Permanente’s Northern California region who scheduled video visits during the last quarter of 2015, a few months after the option became available to patients and providers across the region. Nine out of 10 Kaiser Permanente members who had a primary-care video visit were confident in the quality of care received, reported that the provider was familiar with their medical history, and felt that their health care needs were adequately addressed.
Implementation of a clinical decision support system into the electronic health record that offered risk stratification and decision making guidance increased the number of acute pulmonary embolism patients managed in the outpatient setting.
In a study in the Health Affairs telemedicine issue, Sax and her team found that when patients calling to complain of chest pain were routed to physicians instead of nurses, the calls were shorter, led to fewer emergency department visits and resulted in patients adhering more to the doctors’ advice.
Chest pain is the second-leading reason why people show up in the emergency department. It accounts for about $5 billion of the $80 billion spent annually in the United States on emergency care, according to the Agency for Healthcare Research and Quality. This study finds that “tele-triage” of patients with chest pain over the phone can safely and effectively direct people to the right place for receiving care.
Dr. Vinson and colleagues compared acute PE outcomes in 10 EDs that used an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification versus 11 EDs that did not use the tool. The 16-month study included an 8-month preintervention and an 8-month postintervention period. Adjusted home discharge rates increased at intervention sites from 17.4% pre- to 28% post-intervention. By contrast, no such increase occurred at control sites (15.1% pre- and 14.5% post-intervention).
The Permanente Medical Group honored seven physicians, including members of the Kaiser Permanente Clinical Research in Emergency Services & Treatments (CREST) Network, with the 2018 Morris F. Collen Research Award. “The CREST Network physicians are one of the most exciting and innovative groups we have in research and implementation. They are particularly well-regarded for their work in informatics and clinical decision support and are seen as a model for other specialties,” said Tracy A. Lieu, MD, MPH, director of the Kaiser Permanente Division of Research.
The CREST Network's partners in Minneapolis have developed a new pediatric appendicitis risk calculator (pARC) to aid in the diagnosis of acute appendicitis. This calculator is able to target care specifically to each patient and should reduce the number of unnecessary medical tests and expenses. The calculator is currently being used in a prospective research project at 11 CREST facilities and 6 HealthPartners-affiliated emergency departments to improve appendicitis care in the community setting.
Division of Research Spotlight
A new Kaiser Permanente CREST Network study shows that many patients with acute pulmonary embolism can be safely discharged to their home from emergency rooms without harmful effects. These decisions are facilitated by an online decision tool developed by CREST emergency physician-researchers that incorporates a validated severity index for pulmonary embolism and a list of risk factors for possible adverse outcomes.
This interview accompanies Dr. Mark's publication in the Journal of the American College of Cardiology on acute coronary syndrome in the emergency department. His work assesses 118,822 Kaiser Permanente patients and demonstrates that two validated risk scores are further improved by using lower cutoff levels for cardiac troponin.
Dustin Mark, MD, has been conducting research on acute coronary syndrome in the emergency department. This interview accompanies Dr. Mark's publication in the Journal of the American College of Cardiology. His work assesses the accuracy of three predictive scores and troponin I in predicting patients at low risk of 60-day major adverse cardiac events.
David Vinson, MD, has been conducting research on nights and weekends for much of his 17-year career as an emergency-room physician in The Permanente Medical Group. Now a new program sponsored by TPMG will allow him to dedicate fully a portion of his clinical work week to research, while collaborating with investigators at the Division of Research (DOR).
MedicalResearch.com Interview with Adam Sharp, MD, MS
1) CT use can be avoided for many patients during ED evaluation after head trauma if the Canadian CT Head Rule were applied
2) Application of this rule is very unlikely to miss important injuries or impair patient outcomes
3) An EHR may be able to identify avoidable CT imaging with reasonable margins of error
CDC: Traumatic Brain Injury & Concussion Featured Article
Use of these medications have been associated with an increased risk of bleeding around or within the brain, and posttraumatic injury and death. Close evaluation is needed to identify, and if necessary, reverse the affects these drugs can have on patients experiencing significant bleeding after trauma.
Emergency Quality Network Webinar: Avoidable Imaging Initiative
27:00-49:30 - Dr. David Vinson and Dr. Dustin Ballard discuss the application of eCDS in the ED for PE disposition decisions.
Forbes.com | Pharma & Healthcare
Dr. David Vinson and our Emergency Physician Research Network developed a computerized tool that calculates whether a patient in the emergency room should be admitted into the hospital or can go home safely on medication...Using this tool, physicians have been able to safely send home 50% more patients than before, with no increase in either morbidity or mortality.
Annals of Long-Term Care
In the U.S., the primary out-of-hospital response by ambulance providers is ALS rather than BLS. ALS providers spend more time at the scene (and receive higher reimbursement), but whether this translates into better outcomes for the patient is controversial.
The timely administration of a clot-dissolving treatment for ED patients with acute ischemic stroke nearly doubled following the introduction of new technology, according to a study from the Clinical Research in Emergency Services and Treatments (CREST) Network, a group of emergency medicine physician-researchers affiliated with the Kaiser Permanente Division of Research.
In the emergency department, clinicians must move quickly to treat patients with serious conditions with little margin for error. Based on findings of a recent Kaiser Permanente study, computerized physician order entry (CPOE) can make a meaningful difference when treating individuals presenting with acute ischemic stroke.
"This study demonstrates that computerized physician order entry generally — and an order set embedded with decision support specifically — can facilitate the delivery of time-sensitive interventions for stroke while minimizing errors," said lead author Dustin Ballard, MD, an emergency medicine physician at the Kaiser Permanente San Rafael (California) Medical Center and an adjunct researcher at the Kaiser Permanente Division of Research. "In this case, the investigation showed that these tools can safely lead to more frequent administration of medication to thin blood and break up blood clots in the brain, a treatment that has been associated with better neurological recovery after stroke."
If a patient shows up in the emergency department with a pulmonary embolism (PE), is it safe to send him home? The protocol in many hospitals says absolutely not: The vast majority of PE patients are routinely admitted for several days to monitor their condition and supervise the start of anticoagulants. However, some hospitals are cautiously exploring ED treatment and discharge for PE.
It is now common for emergency department (ED) patients with a new diagnosis of deep venous thrombosis (DVT) to be managed as outpatients, yet despite recommendation by many professional societies, outpatient treatment of ED patients with a new diagnosis of pulmonary embolism (PE) remains uncommon.
Reuters Health Information
Selected patients with newly diagnosed pulmonary embolism (PE) may be safely treated as outpatients, a new systematic review suggests. Dr. David R. Vinson from Kaiser Permanente Roseville Medical Center in Roseville, California, who led the study, described the evolution of the concept in an email to Reuters Health.