The rapid deterioration observed in the condition of some hospitalized patients can be attributed to either disease progression or imperfect triage and level of care assignment after their admission. ...An early warning system (EWS) to identify patients at high risk of subsequent intrahospital death can be an effective tool for ensuring patient safety and quality of care and reducing avoidable harm and costs.
The aim of this study was to prospectively validate a real-time EWS designed to predict patients at high risk of inpatient mortality during their hospital episodes.
Data were collected from the system-wide electronic medical record (EMR) of two acute Berkshire Health System hospitals, comprising 54,246 inpatient admissions from January 1, 2015, to September 30, 2017, of which 2.30% (1248/54,246) resulted in intrahospital deaths. Multiple machine learning methods (linear and nonlinear) were explored and compared. The tree-based random forest method was selected to develop the predictive application for the intrahospital mortality assessment. After constructing the model, we prospectively validated the algorithms as a real-time inpatient EWS for mortality.
The EWS algorithm scored patients' daily and long-term risk of inpatient mortality probability after admission and stratified them into distinct risk groups. In the prospective validation, the EWS prospectively attained a c-statistic of 0.884, where 99 encounters were captured in the highest risk group, 69% (68/99) of whom died during the episodes. It accurately predicted the possibility of death for the top 13.3% (34/255) of the patients at least 40.8 hours before death. Important clinical utilization features, together with coded diagnoses, vital signs, and laboratory test results were recognized as impactful predictors in the final EWS.
In this study, we prospectively demonstrated the capability of the newly-designed EWS to monitor and alert clinicians about patients at high risk of in-hospital death in real time, thereby providing opportunities for timely interventions. This real-time EWS is able to assist clinical decision making and enable more actionable and effective individualized care for patients' better health outcomes in target medical facilities.
To report the success rate and complications associated with peripherally inserted central venous catheters (PICCs) and to compare costs between PICCs and centrally inserted central catheters.
We ...undertook a cohort study of the first 1,000 patients referred to the PICC service of a large tertiary-care, university-affiliated, community hospital. The data were analyzed for insertion success rate, insertion mode, complication rate, successful completion, insertion costs, and applicability of PICCs in “high-risk” groups (transplant, human immunodeficiency virus-infected, intensivecare unit, and pediatric populations).
Of 1,000 consecutive PICC attempts, 963 (96.3%) were successful. Cutdown procedures were necessary in 141 insertions (14.6%). Complications of PICC placement occurred in 170 cases (17.7%). Among the major complications were a need for multiple attempts at insertion in 92 cases, malpositioning in 56, mechanical phlebitis in 37, clotting in 37, and bleeding in 5. The rate for completion of therapy was 68.9%. Frequent reasons for early termination were dislodgment (in 85 cases) and infection (in 72—37 confirmed and 35 potential cases). The rate of confirmed infection was 11 per 10,000 catheter days. The costs of PICC insertion were less than those associated with centrally inserted central catheters.
PICCs can satisfy long-term vascular needs and are safe in many patient populations. The infection rate did not depend on insertion mode, lumen number, or patient's immune status. Use of total parenteral nutrition was the most important risk factor in all patient subsets. Cost and safety considerations strongly favor PICCs as alternatives to other vascular access devices.
Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre- and ...in-hospital care and outcomes from 2008 to 2012 for patients with ST -segment-elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines Registry. In-hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact-to-device for emergency medical systems transport to percutaneous coronary intervention-capable hospitals (93 to 84 minutes), first door-to-device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door-in-door-out at non-percutaneous coronary intervention-capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in-hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years ( P<0.001). Conclusions Quality of care for patients with ST -segment-elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times-to-treatment. In-hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high-risk patients increased.
Background Both heart failure (HF) and chronic kidney disease (CKD) are highly prevalent conditions that often coexist; however, the quality of care received by hospitalized patients with both is not ...known. Methods The Get With the Guidelines—HF registry and performance improvement program prospectively collects data on patients hospitalized with HF. Performance measures to improve treatment of patients with HF and inhospital mortality were examined by kidney function based on glomerular filtration rate (GFR) categorized as normal (GFR ≥ 90), mild (60 ≤ GFR < 90), moderate (30 ≤ GFR < 60), severe (15 ≤ GFR < 30), and kidney failure (GFR < 15 or dialysis). Results Nearly two thirds of hospitalized patients with HF (15,560 patients from 137 hospitals) also had CKD: moderate CKD (43.9%), severe CKD (14.2%), and kidney failure (6.6%). Inpatient mortality was higher for patients with more severe renal dysfunction. Those with kidney failure were significantly less likely to receive nearly all guidelines-based therapies. In contrast, those with moderate or severe CKD often received similar care when compared with those with normal kidney function, except for lower use of angiotensin-converting enzyme inhibitors or receptor blockers (odds ratio 0.19 0.13-0.28 and 0.47 0.36-0.62, respectively) and lower proportions with blood pressure control (odds ratio 0.70 0.58-0.85 and 0.52 0.42-0.63, respectively). Conclusions In a large contemporary cohort of patients hospitalized with HF, we found that renal dysfunction was a highly prevalent comorbidity. Despite higher mortality rates, patients with increased severity of renal dysfunction were less likely to receive important guideline-recommended therapies. Further efforts are needed to improve the care of patients with HF and CKD.
The use of Web-based technology and a collaborative model to improve hospital adherence to secondary prevention guidelines has not been previously evaluated.
Twenty-four hospitals in Massachusetts ...participated in a collaborative that met quarterly, with didactic and best-practice presentations and interactive multidisciplinary team workshops. A customized tool kit and interactive, Web-based management tool were used for data collection and on-line feedback. Data from 1738 patients admitted with coronary artery disease were collected by hospital staff from July 1, 2000, to June 30, 2001. Outcome measures included differences between baseline and 10- to 12-month follow-up measurements of use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, cholesterol measurement and treatment, smoking cessation counseling, blood pressure control, and cardiac rehabilitation referral.
Clinically and statistically significant increases from baseline to 10- to 12-month follow-up were demonstrated in smoking cessation counseling (48% 95% confidence interval CI, 36.6%-58.4% to 87% 95% CI, 73.1%-100.7%), lipid treatment (54% 95% CI, 46.6%-70.2% to 79% 95% CI, 70.2%-88.3%), lipid measurement (59% 95% CI, 51.5%-66.0% to 81% 95% CI, 72.0%-89.5%), and cardiac rehabilitation referral (34% 95% CI, 25.9%-39.7% to 73% 95% CI, 63.2%-82.9%). An improving trend was seen in blood pressure control (60% 95% CI, 55.3%-65.6% to 68% 95% CI, 60.2%-76.1%). High baseline use was maintained for use of aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors.
Implementation of a collaborative quality improvement initiative, interactive training of hospital teams with physician champions, and the use of an interactive Web-based Patient Management Tool enhanced adherence to prevention guidelines in hospitalized patients with coronary artery disease.
Objectives Our purpose was to determine factors independently associated with cardiac rehabilitation referral, which are currently not well described at a national level. Background Substantial ...numbers of eligible patients are not referred to cardiac rehabilitation at hospital discharge despite proven reductions in mortality and national guideline recommendations. Methods We used data from the American Heart Association's Get With The Guidelines program, analyzing 72,817 patients discharged alive after a myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery between January 2000 and September 2007 from 156 hospitals. We identified factors associated with cardiac rehabilitation referral at discharge and performed multivariable logistic regression, adjusted for clustering, to identify which factors were independently associated with cardiac rehabilitation referral. Results Mean age was 64.1 ± 13.0 years, 68% were men, 79% were white, and 30% had diabetes, 66% hypertension, and 52% dyslipidemia; mean body mass index was 29.1 ± 6.3 kg/m2 , and mean ejection fraction 49.0 ± 13.6%. All patients were admitted for coronary artery disease (CAD), with 71% admitted for myocardial infarction. Overall, only 40,974 (56%) were referred to cardiac rehabilitation at discharge, ranging from 53% for myocardial infarction to 58% for percutaneous coronary intervention and to 74% for coronary artery bypass graft patients. Older age, non–ST-segment elevation myocardial infarction, and the presence of most comorbidities were associated with decreased odds of cardiac rehabilitation referral. Conclusions Despite strong evidence for benefit, only 56% of eligible CAD patients discharged from these hospitals were referred to cardiac rehabilitation. Increased physician awareness about the benefits of cardiac rehabilitation and initiatives to overcome barriers to referral are critical to improve the quality of care of patients with CAD.
Significant disparities have been reported in the application of evidence-based guidelines in the treatment of coronary artery disease (CAD) in women and the elderly. We hypothesized that ...participation in a quality-improvement program could improve care for all patients and thus narrow treatment gaps over time.
Treatment of 237 225 patients hospitalized with CAD was evaluated in the Get With the Guidelines-CAD program from 2002 to 2007. Six quality measures were evaluated in eligible patients without contraindications: aspirin on admission and discharge, beta-blockers use at discharge, angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist use, lipid-lowering medication use, and tobacco cessation counseling along with other care metrics. Over time, composite adherence on these 6 measures increased from 86.5% to 97.4% (+10.9%) in men and 84.8% to 96.2% (+11.4%) in women. There was a slight difference in composite adherence by sex that remained significant over time (P<0.0001), but this was confined to patients <75 years. Composite adherence in younger patients (<75 years) increased from 87.1% to 97.7% (+10.6%) and from 83.0% to 95.1% (+12.1%) in the elderly (>or=75 years) over time.
Among hospitals participating in Get With the Guidelines-CAD, guideline adherence has improved substantially over time for both women and men and younger and older CAD patients, with only slight age and sex differences in some measures persisting.
Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre‐ and ...in‐hospital care and outcomes from 2008 to 2012 for patients with ST ‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P <0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years ( P <0.001). Conclusions Quality of care for patients with ST ‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.
Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was ...associated with improvements in adherence.
This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends.
Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.
PDF
