A multi-center collaborative network for emergency medicine research at Kaiser Permanente.
CREST IN THE PRESS
TCTMD
Outpatient Management of Acute PE Remains Underused
2024
Most patients treated in US emergency departments, even those considered low risk, continue to be admitted to the hospital.
"If I had a low-risk PE, I would appreciate avoiding the risks, costs, and inconveniences of an unnecessary hospitalization. Many diverse healthcare systems have implemented successful outpatient PE pathways. Common components include physician education, tools to help identify low-risk patients, and systems to facilitate patient access to anticoagulation and timely follow-up."
-David Vinson, MD
The Permanente Journal
2024
The Permanente Journal is pleased to announce the top-read, most-downloaded articles of 2023.
The list includes two CREST-affiliated studies at #1 and #22: David Vinson's A Case Report of Cold Drinks and Food as a Trigger of Paroxysmal Atrial Fibrillation and Dustin Ballard's CA FIRST (California Febrile Infant Risk Stratification Tool) Algorithm Development in a Learning Health System.
Permanente Medicine
Clinical research drives health care innovation and quality
2023
Research improves safety and clinical effectiveness, leads to medical advancements that benefit all
Kaiser Permanente, one of the nation’s leading integrated health care systems, is known for delivering quality care by expert physicians at its highly rated medical facilities. Less well-known is that it’s one of the nation’s leading health research institutions, with 9 regional research centers that includes the Kaiser Permanente Bernard J. Tyson School of Medicine, where medical students conduct scholarly research projects as part of the curriculum.
ACEPNow
Data-Driven Approach Yields New Approach for Emergency Department Triage
2023
Dana Sax, MD, MPH of the CREST Network embraces a more objective and data-driven approach to ED triage
Emergency medicine involves a density of decision-making that exceeds that of any other medical specialty. Emergency physicians face high-stakes decisions related to diagnosis, treatment, and disposition with limited information and under intense time pressure during every shift. However, the first critical decision in the emergency department (ED) is often not made by physicians, but by emergency nurses. Within minutes of a patient’s arrival, these frontline clinicians are tasked with assigning triage acuity levels that dictate the course of care for individuals and shape the operational efficiency of the entire department.
Division of Research Spotlight
Early-career researchers embrace unique opportunity to improve health care
2023
Postdoc programs enhance the Division of Research and Kaiser Permanente care delivery
The Kaiser Permanente Northern California Division of Research (DOR) is currently hosting one of its largest groups of postdoctoral research fellows. Each of these 11 early-career researchers is working with one or more mentors at the Division of Research to conduct research studies that have the potential to improve health care delivery at Kaiser Permanente — and beyond.
Division of Research Spotlight
Peer support program helps ease physician burnout
2023
Kaiser Permanente study shows innovative outreach program improves well-being
A new Kaiser Permanente physician peer support program designed to reduce burnout helped improve doctors’ well-being and had a positive impact on the culture of the medical departments that took part in the program, Kaiser Permanente researchers found.
Pharmacy Times
Structured Surveillance Rarely Used for Patients with Subsegmental Pulmonary Embolism Despite Recommendations
2023
In addition to the low use of structured surveillance overall, modified CHEST criteria only identified a small portion of patients with subsegmental pulmonary embolism eligible to receive structural surveillance.
Despite guidelines from the American College of Chest Physicians (CHEST), the use of structured surveillance without anticoagulation for patients with subsegmental pulmonary embolism (PE) was low among the small proportion of patients who were eligible, according to the results of a study published in the Journal of the American Medical Association.
MedPage Today
Surveillance Still Not an Option for Many With Subsegmental Pulmonary Embolism
2023
Few patients actually eligible for alternative to anticoagulation
Only a narrow pool of outpatients with acute subsegmental pulmonary embolism (PE) may be candidates for structured surveillance without anticoagulation based on current guideline restrictions, a retrospective study found.
Division of Research Spotlight
Blood thinners still often used to treat patients with small lung blood clots
2023
Kaiser Permanente study finds few patients qualify for surveillance and few physicians recommend it
When a patient arrives in the emergency department with a blood clot in their lungs, blood thinners are typically the first line of treatment. But over the years, questions have been raised about whether the risks associated with blood thinners outweigh the benefits of giving these drugs to patients who have a very small blood clot in a narrow lung artery.
Division of Research Spotlight
Emergency physicians correctly identify patients with lung blood clots who should be hospitalized
2023
Kaiser Permanente study finds doctors use factors beyond risk stratification tools to determine if a patient can safely be treated at home.
Most patients who develop a blood clot in their lungs — an acute pulmonary embolism — are seen in the emergency department, where a physician must determine if they should be hospitalized or can be safely managed at home. A new Kaiser Permanente study found that patients who have a high heart rate or blood clots involving both lungs are more likely to be seen as high risk and subsequently hospitalized, even if they are categorized as low risk on a commonly used risk assessment tool.
Division of Research Spotlight
Widely used triage method overestimates severity of a quarter of emergency department patients
2023
A Kaiser Permanente study looking at the application of the Emergency Severity Index (ESI) — a method commonly used to triage emergency department (ED) patients — found some imprecision, suggesting there may be an opportunity for the ESI to be updated.
The study, which included more than 5 million patient visits at Kaiser Permanente Northern California emergency departments, found the method underestimated the severity of patient conditions 3% of the time, but overestimated severity about 25% of the time. The results were published in JAMA Network Open.
HealthDay
AAP Guidelines Help Detect Invasive Bacterial Infections in Febrile Infants
2022
The American Academy of Pediatrics (AAP) clinical practice guideline (CPG) for management of well-appearing, febrile infants can help detect invasive bacterial infections (IBI) without using C-reactive protein (CRP) and procalcitonin (PCT) with high sensitivity but low specificity, according to a study published online Dec. 9 in Pediatrics.
Tran H. P. Nguyen, M.D., from Kaiser Permanente Northern California in Roseville, and colleagues conducted a retrospective cohort study of infants aged 8 to 60 days presenting at emergency departments between 2010 and 2019 with temperatures ≥38 degrees Celsius who met the inclusion criteria for the AAP CPG. The infants underwent complete blood counts, blood cultures, and urinalysis.
CNN
Opinion: I almost died last year from a medical problem that was entirely preventable
2022
"It started one weekend in November 2021 with stomach cramping, a low fever, chills and vomiting. Soon it became clear I needed to go to the emergency room. By the time I got there, I had low blood pressure, an elevated heart rate, intense abdominal pain and a high white blood cell count.... With guidance from my pediatrician, my parents told the doctors to check for appendicitis. But since I was tender all over my abdomen — not just on my right side — the doctors ruled it out.... In the middle of the night, I was rushed to get an ultrasound that revealed I had a perforated appendix that was leaking a poisonous stream of bacteria throughout my internal organs.
Anupam Kharbanda, pediatric emergency medicine doctor at Children’s Minnesota, came up with what’s called the pARC (pediatric Appendicitis Risk Calculator) score to help assess a child’s probability of appendicitis, using variables such as sex, age, duration of pain, pain migration, white blood cell count and more.... The pARC score could be an important piece of changing diagnostic practices and saving lives."
Division of Research Spotlight
Seeking the best tests for babies with fever
2022
Kaiser Permanente research suggests less invasive options for checking infants for infection. When a parent brings a young baby to the emergency department with a fever, the result is often a challenging medical balancing act. The doctors want to rule out a dangerous bacterial infection but without too many invasive tests that can be harrowing for both infant and parent. New Kaiser Permanente research offers insight into that balancing act, suggesting a national clinical guideline may not be ideal in all health care settings.
The study, published December 7 in Pediatrics, examined a 2021 clinical guideline issued by the American Academy of Pediatrics (AAP) for the evaluation of infants 8-60 days old with fever. The study finds that other protocols may actually work better in certain circumstances by requiring fewer infants undergo extensive further evaluation such as invasive lumbar punctures of the spine and treatments such as intravenous antibiotics and hospitalization.
Division of Research Spotlight
Not all heart failure patients require hospitalization
2022
Kaiser Permanente researchers develop risk calculator to guide hospital admissions from the emergency department. A new risk calculator could help emergency department physicians determine which patients with acute heart failure should be hospitalized and which can safely be discharged and return home, new Kaiser Permanente research suggests.
The retrospective study, published in JACEP Open, included all 26,189 patients who had been treated in a Kaiser Permanente Northern California emergency department for acute heart failure between January 2017 and December 2018. This study suggests that hospitalization may not offer a survival benefit for low-risk patients.
Reuters News
Decision-support tool tied to increased outpatient management of PE
2022
A peer champion-led decision support intervention to increase outpatient management of pulmonary embolism (PE) was sustainable 4 years after implementation, a cohort analysis shows. The researchers suggest that their model could improve sustainability of practice change for other conditions and warrants further study.
As reported in JAMA Network Open, the study was conducted in emergency departments at 21 U.S. community hospitals that had previously participated in the original decision-support intervention trial 4 years earlier: 10 were intervention sites, 11 were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites, compared with controls.
Division of Research Spotlight
Many patients with Blood Clots Can Go Home from ER Safely
2022
A decision support tool implemented in Kaiser Permanente Northern California emergency departments in 2016 has continued to help physicians safely discharge patients with an acute pulmonary embolism to their homes without harmful effects, a new Kaiser Permanente study shows. An acute pulmonary embolism is a blood clot that blocks blood flow to the lungs.
The study was published May 16 in JAMA Network Open. Researchers in Kaiser Permanente’s Clinical Research on Emergency Services and Treatments (CREST) Network developed and then initially evaluated the implementation of an online support tool, called RISTRA (RIsk STRAtification), in 2016. Their research showing the tool could be successfully implemented was published in 2018 in Annals of Internal Medicine.
FOAMcast - An Emergency Medicine Podcast
Primary Care Management of Pulmonary Embolism
2022
Outpatient management of pulmonary embolism for low-risk patients has been encouraged for several years. However, little is known about pulmonary embolism diagnosed and managed exclusively in the outpatient setting. In this study, Vinson et al describe the course of patients diagnosed with PE and managed in the outpatient setting in an integrated healthcare delivery system.
Shownotes/References: FOAMcast.org
Thanks for listening!
Lauren Westafer
Division of Research Spotlight
Some pulmonary embolism patients effectively treated in primary care
2022
Kaiser Permanente study finds not all such patients need to go through the emergency department
Some people who get blood clots in their lungs may be able to skip a visit to the emergency department and be managed safely by their primary care physicians, a new Kaiser Permanente analysis suggests. The study was published January 12 in the Journal of General Internal Medicine.
Division of Research Spotlight
New tool helps EM physicians provide more personalized care to patients with CP
2021
A risk-assessment tool developed by Kaiser Permanente Northern California researchers provides doctors with a more accurate way to assess how likely it is a patient who comes to the emergency department with chest pain will have or die from a heart attack, stroke, cardiac arrest, or other major heart-related problem within the next 60 days, a new study shows.
Division of Research Spotlight
Three clinicians join innovative Kaiser Permanente Northern California research cohort
2020
Three Kaiser Permanente physicians--one of whom is Dana Sax, a valued member of the CREST Network's Steering Committee--have joined The Permanente Medical Group (TPMG) Physician Researcher Program, which allows them to continue their clinical work while pursuing specific research projects. The trio join 10 other clinicians already in the program, which is operated in collaboration with the Kaiser Permanente Division of Research (DOR).
Division of Research Spotlight
Kaiser Permanente Northern California Deepens Its COVID-19 Research Agenda
2020
Investigators from the Kaiser Permanente Division of Research are examining the pandemic's effects from all angles, from clinical trials to predictive modeling. The CREST Network is analyzing COVID-19 patients who are admitted through Kaiser Permanente Northern California emergency departments to better understand which patient are at increased risk for more serious disease.
Journal Watch
Disposition of ED Patients with Pulmonary Embolism Diagnosed Before Arrival
2020
A retrospective CREST study found that patients who received a clinical diagnosis of PE before emergency department arrival were more commonly managed as outpatients than those whose diagnoses were made in the ED. The study also suggests that patients who arrive at the ED with a confirmed PE diagnosis are at lower risk than those with an ED diagnosis, and may thus be able to safely forgo an ED visit.
Division of Research Spotlight
Emergency Physicians Can Use Clinical Experience to Accurately Predict Pediatric Appendicitis
2020
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
Clinical Tool Accurately Predicts Children's Appendicitis Risk in Kaiser Permanente Emergency Rooms
2019
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
Video Visits Convenient and High Quality, Kaiser Permanente Members Say
2019
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.
Clinical Decision Support Tool in ED Increases Outpatient PE Management
2019
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.
Study - Telemedicine Helps More When You Talk to The Expert
2018
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.
Kaiser Permanente “Tele-triage” of Chest Pain Safely Reduces Emergency Room Visits
2018
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.
Web-based Tool Identifies PE Patients Who Can Be Treated at Home
2018
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).
KP Emergency Service Physicians Honored for Research
2018
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.
Technique Developed to Improve Appendicitis Care For Pediatric Patients
2018
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.
New Kaiser Permanente Study Improves Follow-up of Chest Pain in Emergency Department Patients
2018
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.
Risk Scores Combined With Lower Troponin Cut Points May Help Refine Rule-Out Tests for Chest Pain
2018
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.
Permanente Excellence
Physician Researchers Build Bridges to Health Care Innovation
2017
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
Many CT Scans Can Be Avoided During ER Evaluation of Head Trauma
2017
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
2017
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
Optimizing Uptake of Clinical Decision Support in the Electronic Health Record
2016
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
The Human-Machine Equation: How Predictive Analytics Equips Doctors to Take Better Care of You
2016
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
For Most Ambulance Calls, Basic Life Support Trumped ALS in Study
2015
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.
Healthcare Informatics
Research: EHRs with Decision Support Help Optimize Care for Ischemic Stroke Patients
2015
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.
EHR Intelligence
How CPOE Adoption Helps Clinicians Treat Stroke Efficiently
2015
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.
PR Newswire
2015
"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."
ACP Hospitalist
2015
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.
Journal Watch
Certain Emergency Department Patients Newly Diagnosed with PE Can Be Discharged Home
2012
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
Out-of-Hospital Treatment for PE Safe for Selected Patients
2012
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.