Aligning mission to digital health strategy in academic medical centers.

The strategies of academic medical centers arise from core values and missions that aim to provide unmatched clinical care, patient experience, research, education, and training. These missions drive nearly all activities. They should also drive digital health activities - and particularly now given the rapid adoption of digital health, marking one of the great transformations of healthcare; increasing pressures on health systems to provide more cost-effective care; the pandemic-accelerated funding and rise of well-funded new entrants and technology giants that provide more convenient forms of care; and a more favorable regulatory and reimbursement landscape to incorporate digital health approaches. As academic medical centers emerge from a pandemic-related reactionary digital health posture, where pressures to adopt more digital health technologies mount, a broad digital health realignment that leverages the strengths of such centers is required to accomplish their missions.

Hydrogen peroxide vapor decontamination of N95 respirators for reuse.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to global shortages of N95 respirators. Reprocessing of used N95 respirators may provide a higher filtration crisis alternative, but whether effective sterilization can be achieved for a virus without impairing respirator function remains unknown. We evaluated the viricidal efficacy of Bioquell vaporized hydrogen peroxide (VHP) on contaminated N95 respirators and tested the particulate particle penetration and inhalation and exhalation resistance of respirators after multiple cycles of VHP. METHODS: For this study, 3M 1870 N95 respirators were contaminated with 3 aerosolized bacteriophages: T1, T7, and Pseudomonas phage phi-6 followed by 1 cycle of VHP decontamination using a BQ-50 system. Additionally, new and unused respirators were sent to an independent laboratory for particulate filter penetration testing and inhalation and exhalation resistance after 3 and 5 cycles of VHP. RESULTS: A single VHP cycle resulted in complete eradication of bacteriophage from respirators (limit of detection 10 PFU). Respirators showed acceptable limits for inhalation/exhalation resistance after 3 and 5 cycles of VHP. Respirators demonstrated a filtration efficiency >99 % after 3 cycles, but filtration efficiency fell below 95% after 5 cycles of HPV. CONCLUSION: Bioquell VHP demonstrated high viricidal activity for N95 respirators inoculated with aerosolized bacteriophages. Bioquell technology can be scaled for simultaneous decontamination of a large number of used but otherwise intact respirators. Reprocessing should be limited to 3 cycles due to concerns both about impact of clinical wear and tear on fit, and to decrement in filtration after 3 cycles.

Prevention of Nosocomial Catheter-Associated Urinary Tract Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol.

Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection. The authors' baseline rate of CAUTI for general medical service was elevated at 36 per 1000 catheter-days. The medical literature has consistently linked inappropriate catheter use with the development of CAUTI. The baseline data also revealed a high rate of inappropriate use of indwelling urinary catheters. Using the dual modalities of technology through prompts in the computerized order/entry system and handheld bladder scanners, as well as in combination with staff education and nurse empowerment, the authors were successful in reducing the use and duration of urinary catheters as well as the incidence of CAUTI. In subsequent data collection cycles over the following 2 years, 81% reduction in device use and a 73% reduction in the clinical end point of nosocomial CAUTI (36/1000 catheter-days to 11/1000 catheter-days; P < .001) was demonstrated.

Pursuit of Value Drives Strategy to Improve Operations and Outcomes.

The future of American healthcare remains cloudy, with the shifting contours of regulatory and fiscal reform still being shaped. Providers are beset by many challenges that vary but often include state and federal healthcare funding decisions that are antithetical to the interests of patients and aging populations. Regional public health crises and rapidly evolving relationships with third-party payers complicate matters even further.Yale New Haven Health System decided to pursue value as its overriding strategy for navigating the uncertainty in healthcare that is likely to persist for years to come. Many, if not most, of the challenges we face at Yale New Haven Health are shared by health systems across the country; the operational concepts that drive our strategy likely will be familiar. The differentiator is the execution: At Yale New Haven Health, infusing our organization with a culture of high reliability, as well as adopting the practice of clinical redesign, has yielded concrete enhancements in patient care, operational resilience, and financial sustainability. Clinical redesign saved Yale New Haven Health nearly $25 million in direct costs in one year alone.

Association of inpatient and outpatient glucose management with inpatient mortality among patients with and without diabetes at a major academic medical center.

BACKGROUND: Hospitalized patients with diabetes have experienced a disproportionate reduction in mortality over the past decade. OBJECTIVE: To examine whether this differential decrease affected all patients with diabetes, and to identify explanatory factors. DESIGN: Serial, cross-sectional observational study. SETTING: Academic medical center. PATIENTS: All adult, nonobstetric patients with an inpatient discharge between January 1, 2000 and December 31, 2010. MEASUREMENT: We assessed in-hospital mortality; inpatient glycemic control (percentage of hospital days with glucose below 70, above 299, and between 70 and 179 mg/dL, and standard deviation of glucose measurements), and outpatient glycemic control (hemoglobin A1c). RESULTS: We analyzed 322,938 admissions, including 76,758 (23.8%) with diabetes. Among 54,645 intensive care unit (ICU) admissions, there was a 7.8% relative reduction in the odds of mortality in each successive year for patients with diabetes, adjusted for age, race, payer, length of stay, discharge diagnosis, comorbidities, and service (odds ratio [OR]: 0.923, 95% confidence interval [CI]: 0.906-0.940). This was significantly greater than the 2.6% yearly reduction for those without diabetes (OR: 0.974, 95% CI: 0.963-0.985; P < 0.001 for interaction). In contrast, the greater decrease in mortality among non-ICU patients with diabetes did not reach significance. Results were similar among medical and surgical patients. Among ICU patients with diabetes, the significant decline in mortality persisted after adjustment for inpatient and outpatient glucose control (OR: 0.953, 95% CI: 0.914-0.994). CONCLUSIONS: Patients with diabetes in the ICU have experienced a disproportionate reduction in mortality that is not explained by glucose control. Potential explanations include improved cardiovascular risk management or advances in therapies for diseases commonly affecting patients with diabetes.

The safe patient flow initiative: a collaborative quality improvement journey at Yale-New Haven Hospital.

BACKGROUND: Yale-New Haven Hospital (YNHH) began a successful journey to achieve safe patient flow in fiscal year (FY) 2008 (October 1, 2007-September 30, 2008). The 966-bed (now 1,541-bed) academic medical center faced several challenges, including overcrowding in the Adult Emergency Department (ED); delays in the postanesthesia care unit, which affected the flow of patients through the operating rooms; pinched capacity during the central part of the day; and a lack of interdependent institutionwide coordination of patients. METHODS: The Safe Patient Flow Steering Committee oversaw improvement efforts, most of which were implemented in FY 2009 (October 2008-September 2009), through a cascade of operational meetings. Process changes were made in various departments, such as the Adult ED, Physicians/Providers, and the Bed Management Department. Organizationwide method changes involved standardizing the discharge process, using status boards for visual control, and improving accuracy and timeliness of data entry. RESULTS: Between FY 2008 and FY 2011, YNHH experienced an 84% improvement in discharges by 11:00 A.M. The average length of stay decreased from 5.23 to 5.05 days, thereby accommodating an additional 45 inpatients on a daily basis, contributing to YNHH's positive operating margin amid increasing volume and overall decreasing inpatient length of stay. CONCLUSIONS: YNHH improved clinical, operational, and financial outcomes by embracing five key components of demand capacity management: real-time communication, inter/intradepartmental and interdisciplinary collaboration, staff empowerment, standardization of best practices, and institutional memory.

Evaluating inpatient glycemic management: the Quality Hyperglycemia Score.

BACKGROUND: Inpatient hyperglycemia has become a major focus at many hospitals. However, although several professional organizations have pushed for improved inpatient glucose management, glycemic control at many institutions remains suboptimal. There is a general consensus that improved quality of care is needed, but objective assessment of care quality remains a challenge. Lack of clear, effective performance feedback to clinicians is one element that may derail efforts to improve practice. METHODS: We developed a simplified grading system, the Quality Hyperglycemia Score (QHS), to allow clinicians and managers to easily review and compare glycemic management on adult medical-surgical and intensive care units over the prior 3 months and to more fully engage patient care teams in quality improvement. RESULTS: The QHS represents a single value from 0 to 100, incorporating elements of glycemic management influenced by all team members. The scoring system rewards the maintenance of blood glucose levels in or near the normal range and adherence to the hospital policy on the use of bedside glucose meters, but penalizes frequent hypoglycemic episodes and severe hyperglycemic excursions. Each element is weighted independently and summed to produce the QHS. Scores then correspond to a color code highlighting each unit's performance level. CONCLUSIONS: To date, the QHS reflects the spectrum of blood glucose management at our hospital. While refinement and internal and external validation with clinical outcomes are planned, we propose the QHS as a standardized, objective measure of the quality of inpatient glycemic management.

Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol.

Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection. The authors' baseline rate of CAUTI for general medical service was elevated at 36 per 1000 catheter-days. The medical literature has consistently linked inappropriate catheter use with the development of CAUTI. The baseline data also revealed a high rate of inappropriate use of indwelling urinary catheters. Using the dual modalities of technology through prompts in the computerized order/entry system and handheld bladder scanners, as well as in combination with staff education and nurse empowerment, the authors were successful in reducing the use and duration of urinary catheters as well as the incidence of CAUTI. In subsequent data collection cycles over the following 2 years, 81% reduction in device use and a 73% reduction in the clinical end point of nosocomial CAUTI (36/1000 catheter-days to 11/1000 catheter-days; P < .001) was demonstrated.