Recent Studies in Healthcare Research
Information Systems for Detecting and Managing Acute Kidney Injury
The MIND ICU Study
Safe Critical Care: Testing Improvement Strategies
Information Systems for Detecting and Managing Acute Kidney Injury
Acute Kidney Injury (AKI) is a common complication among hospitalized patients and heralds a 3 to 5 fold increase in mortality, increased costs, and potential lifelong dependence on dialysis. While clinical decision support systems (CDSS) have previously assisted with the medical management of chronic kidney disease, there has been no validated approach for a CDSS to identify AKI and facilitate a medical intervention at an early stage. We plan to develop an AKI detection algorithm using laboratory and bedside measurements that are typically available in electronic medical records. We will validate the algorithm against the judgment of an expert nephrology review panel and use the latest published standards for AKI staging. As a second step, we plan to create models (using both traditional and machine learning approaches) that predict progression of AKI by incorporating comorbidities, admission diagnoses, and exposure to nephrotoxic therapies. Once the electronic criteria for early AKI are defined, we will build and evaluate a hospital-wide CDSS for managing early AKI. The goal is to prevent AKI progression and the associated complications of hypokalemia, acidemia, and medication toxicity. Funded by the National Library of Medicine Investigators: Josh Peterson, M.D., M.P.H. (PI); Michael Matheny, M.D., M.P.H.; Randolph Miller, M.D.; Julia Lewis, M.D.; Alp Ikizler, M.D.; Eddie Siew, M.D.; Russ Waitman, Ph.D.; Joshua Denny, M.D., M.S.
The MIND ICU Study
Among Intensive Care Unit (ICU) survivors, subsequent cognitive and functional decline are the greatest threats to meaningful recovery. Six small cohorts indicate that an alarming 30% to 80% of the increasingly older millions of ICU survivors develop an acquired long-term cognitive impairment (LTCI) functionally equivalent to mild/moderate dementia that may last years. Additionally, major deficits in health-related quality of life (HRQL), functional status, and an “ICU accelerated” frailty are common, especially in the elderly. A leading and potentially modifiable risk factor for these devastating outcomes may be ICU delirium, which is a predictor of higher mortality, higher cost, and poor cognitive function at discharge. Additionally, heavy and prolonged exposure to potent psychoactive medications routinely administered in high doses to ventilated patients may have lasting yet preventable cognitive and functional effects. In this proposal, Aims 1 and 3 will determine whether delirium is an independent risk factor for the incidence, severity, and/or duration of LTCI (Aim 1) and impaired HRQL (Aim 3) in ICU survivors. Likewise, Aims 2 and 4 will determine whether degree of exposure to sedative and analgesic medications in ICU patients is an independent risk factor for the incidence, severity, and/or duration of LTCI (Aim 2) and impaired HRQL (Aim 4). The MIND- ICU study will be a prospective cohort study enrolling 800 mechanically ventilated medical and surgical patients from 3 diverse medical centers over a 39 month period with comprehensive follow-up testing at 3 and 12 months after hospital discharge. This study will quantify whether delirium and sedative/analgesic exposure are indeed risk factors for LTCI and HRQL, controlling for other covariates such as age, medical vs. surgical ICU admission, pre-existing cognitive impairment, sepsis, and apoE genotype. This will pave the way for development of preventive and/or treatment strategies to reduce long-term cognitive impairment and improve the functional recovery of older and younger ICU patients for decades to come. Funded by the National Institute on AgingInvestigators: Wes Ely, M.D., M.P.H.
Safe Critical Care: Testing Improvement Strategies
Our project leverages the Institute for Healthcare Improvement (IHI) national “100,000 Lives Campaign” directed at six initiatives for safer and improved health care. Our focus will be on two of these initiatives bundled together to Improve Critical Care – reduction of catheter-related blood stream infections and ventilator-associated pneumonia – across 147 of the medical/surgical and children’s hospitals of the Hospital Corporation of America (HCA). The pragmatic purpose of this project is to implement evidence-based practices for improvement of critical care in the intensive care unit (ICU), collect information that will inform others on strategic approaches to such implementation, and plan for sustained spread across the large HCA health care network. Embedded in this project is research evaluating “Breakthrough Collaboratives.” Deliverables for the AHRQ “Partnerships in Implementing Patient Safety” include an implementation toolkit to assist uptake and spread of these safe practices across the system of health care. In this study, one group of HCA medical centers will participate in the Campaign to Improve Critical Care and receive a Tool Kit for implementing this initiative. Although Tool Kits may help to enable change, similar to continuing medical education, providing tool kits is a passive approach to change that does not assure transfer to frontline behavior. Our comparative strategy is to conduct a collaborative that actively engages teams in the work of improvement and, in this case, safe practices for critical care. Thus, our project not only directs its focus on implementing safe practice for critical care but tests the incremental value of a collaborative for improvement to a tool kit and safe practice campaign. Our hypothesis is that the strategies for implementing safe critical care practice will differ in level of achievement whereby the Collaborative group will perform better than the Tool Kit-Campaign group. The outcome measure will be clinical event rates and an index of safe practices that represent a bundling of key process measures related to evidence-based practices for preventing catheter-related blood-stream infections and ventilator-associated pneumonia in the intensive care unit. Thus, our project aims are to: 1. Implement a campaign for Improving Critical Care (blood-stream infections and ventilator-associated pneumonia) as part of the IHI 100,000 Lives Campaign. 2. Develop tool kits for reducing blood-stream infections and ventilator-associated pneumonia. 3. Conduct a randomized controlled trial to compare the effectiveness of a Collaborative versus Campaign and Tool Kit strategy for implementing an improvement initiative. 4. Examine the organizational and provider factors that contribute toward and enable successful performance improvement. Funded by the Agency for Healthcare Research and Quality Investigators: Theodore Speroff, M.D.