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Title: Reducing Harm in Pediatrics: A Davies Story

Session 132, March 7, 2018

Speakers:

Brian R Jacobs, MD,CIO, CMIO, Children’s National Health System

Shireen M. Atabaki, MD, MPH, , Children’s National Health System

Jonathan Palma, MD, MS, Stanford Children’s Health

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Brian R. Jacobs, MD, Children’s National Health System

Shireen Atabaki, MD, MPH, Children’s National Health System

Jonathan Palma, MD, MS, Stanford Children’s Health

Have no real or apparent conflicts of interest to report.

Conflict of Interest

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AgendaIn the first use case the team at Children’s National Health System will present their successful efforts to increase patient engagement and improve patient outcomes, through their health IT optimization for pediatric concussion care

• Background

• Local Problem

• Governance, Design and Implementation

• Value Derived

• Future Advancement

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Learning Objectives• Understand the role of workflow-integrated clinical decision support

in improving outcomes

• Learn about rapid clinician adoption of technology and knowledge translation

• Understand financial savings which can result from integrated EHR utilization

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Head Injury CT Scan and Quality Shireen M. Atabaki, MD, MPH

Medical Director, Informatics, Program Director, Telemedicine

Children’s National Health System

Brian R Jacobs, MD

CIO, CMIO, Children’s National Health System

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Background

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Pediatric Concussion and CT Data

Most frequent diagnosis for injured child is:

HEAD INJURY

• Each year in the US:

– 5 million children

– Over 1 million ED visits

• 4 million pediatric CTs

– 20 fold increase 1995-2003

Faul M, Centers for Disease Control, 2010

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Partnership Launching with Bear Institute in 2013

• 1st pediatric Health IT Institute in the country

• Mission is to foster innovation, advance clinical care, and create a world-class IT structure to improve outcomes and service.

• Institute works to accelerate the development of fully-integrated , accessible EHR via advanced health IT capabilities

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• 313-bed acute care hospital• 2 pediatric emergency departments• Level I trauma center• Critical care transport program• Community-based primary care network• Primary care offices in DC and MD• 7 regional outpatient centers• Ambulatory surgery center• School nurse program• Medical collaborations across the region• Mobile health services

Serving over 219,000 patients/year: regionally, nationally, and from 21 countries

• $ 1.1 B Budget Health SystemIn FY 17:• Discharges – 15,554• Emergency Room Visits – 120,648• Outpatient Visits – 560,810• Surgery Cases – 17,535

Children’s National At a Glance

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How Health IT supports our mission• Supports Organizational Transformation – Integrated and interoperable Health IT

systems support evidence based, high quality care for kids, with improved outcomes

and an overall reduction in cost. e.g. decision support and practice guidelines

• Patient Engagement – Innovating the way we use Health IT can empower our

patients/families to take an active role in their care. e.g. patient portals, mobile device

tools, and Telehealth

• Improvement in Care Delivery, Outcomes, and Patient Safety – Robust Health IT,

providers have data and devices at the bedside, allowing them to spend more time with

their patients. e.g. Ambulatory EHR

• Propelling Innovation and Research – Sophisticated Health IT capabilities enable

advances in medicine. e.g., genomics, matching patient information with a database of

open clinical trials for research and population health

.

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Local Problem

12March 5, 2018

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• Risks of lethal malignancies

– Cranial CT = 100 x radiation of CXR

– CT in 1st 22 years of life = 300% increase in lifetime cancer

– 1/1100 infants w/ lethal malignancies

• NCI and FDA issued warnings in 2001

March 5, 2018Pearce et al., Lancet, 2012

Pediatric Concussion and CT Radiation

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PECARN CT Decision Rules, 2009 • N=44,000 children• CDS to detect clinically important brain injury• 99.9% Negative Predictive Value

Kuppermann, Holmes, Dayan, Hoyle, Atabaki et al., Lancet, 2009

Evidence Based Medicine at CNHS

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• 10 fold variation btw Providers in CT

• CT rates 30%

• 1000 CTs annually

• Over 92% of CT scans were normal

• Percentage did not improve 2009-11

• Traditional KT is slow – 10-13 years

Zerhouni, NIH

Pre-implementation CT Rates

Provider

% O

rderi

ng

a H

ead

CT

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How Health IT was Utilized

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Evidence Based

Medicine

Improved Outcomes

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CNMC CPOE Decision Support

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Governance

• Goal: Decrease % of children with concussion who had a head CT ordered in our Emergency Departments

• Team

– SMEs in ED/Trauma/ Nursing/ IT/ Education

– Project Manager

– Analyst

– Project Architect

Patient Safety

Quality Improvement

Evidence Based

Medicine

Health ITBest

Concussion

Care

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Previous Process

March 5, 2018

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Current Process

March 5, 2018

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Value Derived

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Outcomes: Radiation & Cost Reduction

• Radiation Reduction:

– 44% relative reduction in CT scan rate

Pre: 1000 (27%) to Post: 444 (11.9%)

• Cost Reduction:

– 556 avoided head CT scans

– $875,144 cost reduction per year

– No untoward outcomes

March 5, 2018

Atabaki, Jacobs et al., Ped Quality & Safety, 2017

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Proportion of Concussion Patients with CT

March 5, 2018

0%

5%

10%

15%

20%

25%

30%

35%Intervention

y = -0.0138x + 0.258R2 = 0.7621

y = 0.0002x + 0.2394R2 = 0.0002

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Outcomes Data

March 5, 2018

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Future Advancement

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Goal #1: Health IT for Knowledge Translation to Improve Quality

March 5, 2018

• EBM models can be transferred across EHRs

• Abdomen CT (trauma, appendicitis)

• Head CT (seizure, headache, VP shunt)

• City wide collaboration

• National and International EBM dissemination

• Provider education strategiesMeaningful Use in Oklahoma & the District of Columbia, AHRQ 2015

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Goal #2: Shifting the Paradigm of Concussion Care

March 5, 2018

• CDC Funded Project

– Created effective diagnostic tools for ED

– Created education for outpatient

– Communication to school and PCP

– Improve Outcomes

CDC Grant 1U49CE001385-01

Zuckerbraun, Atabaki, Collins, Gioia et al, Pediatrics, 2015

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Mobile Apps for Patients and Families

March 5, 2018

• Developed a mobile health solution that communicates via the EHR to the concussion screening information

– Allows for patients to be Rxed mobile App and go home with a concussion check-list and daily reminders

– Provides secure communication with the patient’s school nurse and primary care physician

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Stanford Children’s HealthOver 80 ACGME-accredited

residency & fellowship

programs

500,000+Ambulatory Patient Visits Per Year

60+ Bay Area Locations

Our obstetric, neonatal

& developmental

medicine services are

all in one location;

the only children’s

hospital in the Bay

Area and one of a few

in the country to offer

all three

725+Stanford Medicine Doctors

New family friendly,

environmentally

sensitive, &

technologically

advanced children’s

hospital with

361 inpatient beds

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• Nephrotoxins and Acute Kidney Injury

• Clinical Case

• NINJA Collaborative

Local Problem

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• Hospitalized children have become more ill, more complicated

More therapies and

polypharmacy

Nephrotoxins are ... toxins

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• Nephro means kidney and toxin means, well, toxin

– Cause acute kidney injury (AKI) and failure

– AKI increases mortality, length of stay (LOS), and chronic kidney disease (CKD)

Nephrotoxins are ... toxins

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Clinical Case

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Clinical Case

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Kidney International, 2016

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• Identify nephrotoxic medication (NTMx) exposure:

• Aminoglycoside for > 3 days (or)

• > 3 nephrotoxins simultaneously

• Recommends screening for AKI daily using serum creatinine

• Increase awareness, prompt conversation about nephrotoxins

NINJA CollaborativeNephrotoxic Injury Negated by Just-in-time Action

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NINJA CollaborativeNephrotoxic Injury Negated by Just-in-time Action

Mission: Eliminate all preventable cases of nephrotoxic medication associated AKI in hospitalized children

Vision: Children should only get the nephrotoxic medications they need for the duration they need them

Armed with a Mission, a Vision, a list of nephrotoxins, and …

actually, not much else

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• Identification of the Project Team

• Development of the Workflow

• Definition of Intended Outcomes

Design and Implementation

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Nephrology: Scott Sutherland, MD

Pharmacy: Tiffany Tesoro, PharmD

Clinical Informatics: Jonathan Palma, MD, MS

IS Analytics: Emilie Tan, Analyst

Identification of Project Team

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IntroductionDefinition of

RequirementsProposed Workflow

Workflow Iteration

• Project Team

• NINJA goals/

objectives

• Define roles

• Establish

timeline

• Identify nephrotoxin-

exposed patients

• Communicate

exposure to care

team

• Define clinical

intervention and

recommendations

• Electronic report

• Communication

plan (PharmD)

• Recommend:

screen for AKI,

discuss tx

regimen

• Review and

revise IT solution

• Grow

relationship with

clinical teams

• Refine recs:

change, d/c

meds; adjust

dosing

Development of the Workflow

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Definition of Intended Outcomes

Aligned with the NINJA Collaborative:

• Rate* of Nephrotoxic Medication (NTMx) exposure

• Rate* of Acute Kidney Injury AKI (Creatinine > 1.5x baseline)

*per 1000 non-ICU patient days

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• Clinical Workflow

• IT Solution: NINJA Report

– Structure

– Logic

– Evolution

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How Health IT was Utilized

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👩

�👩👧👦

�

Clinical

PharmacistCare Team

Laboratory

screening

Medication

adjustment

s• Identify pts with

NTXm exposure

• Communicate exposure

to care team

• Recommend screening

labs (daily creatinine)

• Consider labs: serum creatinine, drug levels

• Consider meds: dosage, duration, and alternative

agents

Clinical Workflow

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NINJA Collaborative

Nephrotoxic Medications Nephrotoxin exposure Recommendation

✅ Aminoglycoside for > 3

days

(or)

✅ > 3 nephrotoxins at once

� Screen for AKI daily

using serum creatinine

� Check drug levels

� Discuss dose/duration of

and alternatives to

nephrotoxic medications

Goldstein et al. Kidney International,

2016.

aMedications counted for 7d following

administration (long half-life); all others

counted for 48h.

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👩

�

👩👧👦�

Clinical

Pharmacist

Care Team

Laboratory

screening

Medication

adjustment

s

�

NINJA

Report

Clinical Workflow with IT Solution

• Run NINJA report,

identify pts with NTXm

exposure

• Communicate exposure to

care team

• Recommend screening labs

(daily creatinine)

• Consider labs: serum creatinine, drug levels

• Consider meds: dosage, duration, and alternative agents

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Nephrotoxic Medications Ordered

(Start, End, Last Dose)

Laboratory

Information

(Creatinine)

Patient Information

(MRN, Name,

Location)

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> 3 nephrotoxins

simultaneously

Aminoglycoside for

> 3 days

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• Content

– Added Stem Cell Transplant and Hematology/Oncology

– Expanded nephrotoxin list from 45 to 61 items

• Implementation

– SAP Business Objects report (-24h) to Epic Reporting Workbench (real-time)

NINJA Report: Evolution

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Clinical Case

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NINJA

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NINJA

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NINJANINJA

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NINJANINJA

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• Value Derived

– Reduced nephrotoxin exposure

– Reduced AKI

• Clinical Impact

Value Derived

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62*358 pt days screened/wk = 18,616 pt days screened /year

Value Quantified

• Nephrotoxin Exposure

– Stanford Children’s intervention reduced exposure rate by 39%

– Annual exposure rate = 404 exposures/year

Prevented 158 NTMx exposures per year

• AKI

– Intervention reduced AKI rate by 44%

– Annual AKI rate = 113 cases of AKI/year

Prevented 50 AKI events per year

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• Continued adjustments (+/-) to nephrotoxin list and logic

• Extension to ICU/CVICU population (high risk populations where a dedicated pharmacist is already present)

• Augmentation of AKI prevention with intelligent alerts, e.g. for IV contrast as an additional exposure

• Extension to other teams (prompting hiring of additional clinical pharmacists)

• Enhancing report with medication levels

Ongoing Improvements

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Questions?

Jonathan Palma, MD, MSClinical Associate Professor, Neonatal-Perinatal Medicine

Program Director, Clinical Informatics Fellowship

Medical Director, Clinical Informatics Innovation

Twitter: @jonpalma180

LinkedIn: @jonpalma

http://profiles.stanford.edu/jonathan-palma

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