2/21/19 | Delivering Results
Managing Emergency Department Overcrowding With NEDOCS
In collaboration with Cerner’s Emergency Medicine group, Tiger Institute developed the National Emergency Department Overcrowding Score (NEDOCS) component for display on the ED Real Time Dashboard. The NEDOCS algorithm provides an overcrowding score based on factors in the ED, including number of waiting patients, free beds, and ED patients on ventilators — among others.
By sending alerts to providers and hospital administration, staff can mitigate the factor(s) contributing to department overcrowding, and to get patients seen and moved to the appropriate level of care more quickly.
Our development work is available to the broader Cerner ED Dashboard client base, and as such, the NEDOCS component and alerting system now provide value to more than 15 health systems.
Making Surgery Easier for Patients and Families
Team InteGrated Enhanced Recovery (TIGER) is a new protocol, which helps MU Health Care better prepare patients, shorten hospital stays, make pain more manageable, and reduce direct costs associated with radical cystectomy (a procedure where surgeons remove all or part of the bladder.) Because of the protocol’s success, the team is adapting it to impact other kinds of surgical procedures.
Tiger Institute associates and MU Health Care staff members built new tools in the EHR to track patients’ progress and lay out a daily care plan. A nurse navigator helps guide each patient along all steps of his or her surgery — from preparation to post-operation.
Improved pain management
The TIGER protocol encourages preemptive pain medications and informs patients about alternatives to narcotics for pain management.
Three days after the operation, patients in traditional care used a total median of 413 morphine milligram equivalents (MME), while those using the TIGER protocol had a median of 275 MME.
Improved care plans, fewer drugs and other improvements helped patients spend less time in the hospital. Those who experienced the normal procedure had an average length of stay (ALOS) of 10.5 days. However, those who used the TIGER program had an ALOS of only six days.
Patients didn’t realize they were going home four days sooner,” said Mark Wakefield, MD, associate chief medical officer. “They were better prepared for surgery, more engaged in their own recovery, had less post-operative pain, and returned to a better condition sooner after surgery.
A reduced length of stay, along with fewer drugs and other items related to surgeries, helped reduce the median cost of a cystectomy surgery by 25%.
Similar work continues to improve other major surgical cases, such as liver or pancreas resections, colon surgeries and lung surgeries. These teams have already started developing protocols and are in various stages of implementation.
Sepsis Bundle Compliance
Sepsis is the leading cause of hospital mortality. Sepsis diagnoses are present in 40% of MU Health Care’s mortalities. Compliance with the 3- and 6-Hour Sepsis Bundles (a set of early interventions to be performed within 3 and 6 hours of identification, aimed at reducing sepsis mortality) are critical. Dashboards have been developed for retrospective analysis, however real-time information is necessary for timely, appropriate care.
The Tiger Institute Development at the Edge (TIDE) team has developed a first-of-its-kind, Sepsis Bundle Compliance Tool which gives providers real-time insight into the multi-factor, narrow bundle compliance time line and enables them to ensure appropriate care is delivered in a timely manner. The tool indicates whether each element was met, is at-risk of being out of compliance, or was not met. Providers can also review relevant clinical information including lab results, medication administration times, and fluids administered directly within the tool.
We believe real-time information to support standardization of care will support bundle compliance and result in a corresponding reduction in Sepsis mortality.
SMART Results Graphing
Only about half of the 78 million US adults diagnosed with hypertension have their blood pressure (BP) controlled. Recent research has identified the important role of home BP measurements, considered equal, or even superior, to clinic BP measurements in their predictive value.
However, home BP data in its numerical form—often provided by patients as written notes or submitted through telehealth applications—may not be used to its fullest potential. Visualization of home blood pressure data values may prove to be the solution; however, current EHR systems do not have adequate capabilities for informative visualizations of home-entered values.
Beginning in February 2017, our TIDE team designed and developed a graphical display of BP measurements and provided for patients to easily record home BPs through their MU patient portal account. The team used Fast Healthcare Interoperability Resources (FHIR) standards to develop this view for both patients and physicians.
The physician view accommodates numerous patient-entered home BPs and includes intuitive display of target range and a smoothing line indicating rolling average. This view, which makes judgment about BP control more accurate, is now available (since February 2018) with the patient portal and within workflows for ambulatory primary care physicians in the Cerner Millennium EHR.
The team also developed a medication time line to correspond with times of home and/or clinical BP measurements. This can help a clinician more easily determine the effects of medication on a patient’s blood pressure so he or she can make a more informed adjustment to drugs and/or dosage. Research evaluation is underway.
Thomas Selva, M.D., chief medical information officer for University of Missouri Health Care, and Seth Katz, associate administrator of information management at the Truman Medical Centers in Kansas City, Mo., spoke at HIMSS 2017 about how IT governance structures evolved at their institutions.
University of Missouri Health Care and the Tiger Institute for Health Innovation have received the Transformational Leadership Award from the College of Healthcare Information Management Executives (CHIME) and the American Hospital Association.
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