Rolling Up the Sleeve: Equitable, Efficient, and Safe COVID-19 Mass Immunization for Academic Medical Center Employees.

BACKGROUND: Novel coronavirus disease 2019 (COVID-19) vaccine administration has faced distribution barriers across the United States. We sought to delineate our vaccine delivery experience in the first week of vaccine availability, and our effort to prioritize employees based on risk with a goal of providing an efficient infrastructure to optimize speed and efficiency of vaccine delivery while minimizing risk of infection during the immunization process. OBJECTIVE: This article aims to evaluate an employee prioritization/invitation/scheduling system, leveraging an integrated electronic health record patient portal framework for employee COVID-19 immunizations at an academic medical center. METHODS: We conducted an observational cross-sectional study during January 2021 at a single urban academic center. All employees who met COVID-19 allocation vaccine criteria for phase 1a.1 to 1a.4 were included. We implemented a prioritization/invitation/scheduling framework and evaluated time from invitation to scheduling as a proxy for vaccine interest and arrival to vaccine administration to measure operational throughput. RESULTS: We allotted vaccines for 13,753 employees but only 10,662 employees with an active patient portal account received an invitation. Of those with an active account, 6,483 (61%) scheduled an appointment and 6,251 (59%) were immunized in the first 7 days. About 66% of invited providers were vaccinated in the first 7 days. In contrast, only 41% of invited facility/food service employees received the first dose of the vaccine in the first 7 days (p < 0.001). At the vaccination site, employees waited 5.6 minutes (interquartile range [IQR]: 3.9-8.3) from arrival to vaccination. CONCLUSION: We developed a system of early COVID-19 vaccine prioritization and administration in our health care system. We saw strong early acceptance in those with proximal exposure to COVID-19 but noticed significant difference in the willingness of different employee groups to receive the vaccine.

Superior vena cava stenosis presenting with bendopnea.

Bendopnea, or dyspnoea with bending forward, is a recently described symptom of heart failure that is associated with elevated ventricular filling pressures. Here, we describe a case of superior vena cava (SVC) stenosis that presented with bendopnea and resolved with SVC recanalisation. We suggest that SVC stenosis be considered in the differential diagnosis of patients who experience bendopnea.

User stories as lightweight requirements for agile clinical decision support development.

OBJECTIVE: We sought to demonstrate applicability of user stories, progressively elaborated by testable acceptance criteria, as lightweight requirements for agile development of clinical decision support (CDS). MATERIALS AND METHODS: User stories employed the template: As a [type of user], I want [some goal] so that [some reason]. From the "so that" section, CDS benefit measures were derived. Detailed acceptance criteria were elaborated through ensuing conversations. We estimated user story size with "story points," and depicted multiple user stories with a use case diagram or feature breakdown structure. Large user stories were split to fit into 2-week iterations. RESULTS: One example user story was: As a rheumatologist, I want to be advised if my patient with rheumatoid arthritis is not on a disease-modifying anti-rheumatic drug (DMARD), so that they receive optimal therapy and can experience symptom improvement. This yielded a process measure (DMARD use), and an outcome measure (Clinical Disease Activity Index). Following implementation, the DMARD nonuse rate decreased from 3.7% to 1.4%. Patients with a high Clinical Disease Activity Index improved from 13.7% to 7%. For a thromboembolism prevention CDS project, diagrams organized multiple user stories. DISCUSSION: User stories written in the clinician's voice aid CDS governance and lead naturally to measures of CDS effectiveness. Estimation of relative story size helps plan CDS delivery dates. User stories prove to be practical even on larger projects. CONCLUSIONS: User stories concisely communicate the who, what, and why of a CDS request, and serve as lightweight requirements for agile development to meet the demand for increasingly diverse CDS.

"D/C the CC (Carbon Copy)" - Improving the EHR Signal-to-Noise Ratio for Clinicians by Selective Feature De-Implementation.

De-implementation of a 10-year EHR configuration resulted in over 50% decrease in the volume of the most-common InBasket message type received by PCPs. Pro-actively seeking out ways to not only (a) implement helpful new EHR features but (b) de-implement detrimental ones offers an opportunity to accelerate improvement in the S/N ratio and reduce clinician frustration and dissatisfaction with the EHR. Balancing governance decision agendas with de-implementation opportunities can enhance the clinician experience.

Implementing Shared, Standardized Imaging Protocols to Improve Cross-Enterprise Workflow and Quality.

Value-based imaging requires appropriate utilization and the delivery of consistently high-quality imaging at an acceptable cost. Challenges include developing standardized imaging protocols, ensuring consistent application by technologists, and monitoring quality. These challenges increase as enterprises grow in geographical extent and complexity through mergers or partnerships. Our imaging enterprise includes a university hospital and clinic system, a large county hospital and healthcare system, and a pediatric hospital and health system. Studies across the three systems are interpreted by one large academic radiology group with expertise in various subspecialties. Our goals were as follows: (1) Standardize imaging protocols; (2) adapt the imaging protocols to specific modalities and available equipment; and (3) disseminate this knowledge across all of the sites of care. Our approach involved three components: (1) facilitation of imaging protocol definition across subspecialty radiologist teams; (2) creation of a database which links the clinical imaging protocols to the scanner/machine specific acquisition protocols; and (3) delivery of a protocol library and updates to all users regardless of location. We successfully instituted a process for the development, implementation, and delivery of standardized imaging protocols in a complex, multi-institutional healthcare system. Key elements for success include (1) a Project Champion who is able to articulate the importance of protocol standardization in improving the quality of patient care, (2) strong, effective modality-specific operational committees, (3) a Project Lead to manage the process efficiently, and (4) an electronic publishing of the protocol database to facilitate ease of access and use.

Acute pulmonary embolism: endovascular therapy.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Predicting Success in Percutaneous Transhepatic Biliary Drainage.

PURPOSE: To develop a model to predict successful bilirubin decrease following percutaneous biliary drain placement. METHODS: A total of 257 patients who were identified having undergone percutaneous transhepatic biliary drain placement (PTBD) at our institution between 2002 and 2013 had their medical records and imaging reviewed. Of those, 190 of these patients met criteria and were used in the analysis. A regression model was performed on logarithm-transformed collected variables to predict post-drainage logarithmic transformed total bilirubin levels. A stepwise variable selection method based on Schwarz Bayesian Information Criterion was used to select the most closely associated variables. The model was validated with a Monte Carlo simulation. A short program was developed to calculate the point estimate using the model developed and compared to actual values. RESULTS: The variables that best predicted bilirubin reduction were initial Tbl (PrTbl), INR and ALT. The selected model had a root mean squared error of 0.8. The model had a negative predictive value (PoTbl is below 2 mg/dL) of 83%. CONCLUSIONS: PTBD may not achieve decreasing bilirubin in patients with a malignant obstruction. This is an initial model that can help determine which patients may not benefit from PTBD placement. With more patients, the model's validity can be increased and provide useful clinical determinant to aide patient care.

Agile Co-Development for Clinical Adoption and Adaptation of Innovative Technologies.

Even the most innovative healthcare technologies provide patient benefits only when adopted by clinicians and/or patients in actual practice. Yet realizing optimal positive impact from a new technology for the widest range of individuals who would benefit remains elusive. In software and new product development, iterative rapid-cycle "agile" methods more rapidly provide value, mitigate failure risks, and adapt to customer feedback. Co-development between builders and customers is a key agile principle. But how does one accomplish co-development with busy clinicians? In this paper, we discuss four practical agile co-development practices found helpful clinically: (1) User stories for lightweight requirements; (2) Time-boxed development for collaborative design and prompt course correction; (3) Automated acceptance test driven development, with clinician-vetted specifications; and (4) Monitoring of clinician interactions after release, for rapid-cycle product adaptation and evolution. In the coming wave of innovation in healthcare apps ushered in by open APIs to EHRs, learning rapidly what new product features work well for clinicians and patients will become even more crucial.

Safety and Effectiveness of the Denali Inferior Vena Cava Filter: Intermediate Follow-Up Results.

PURPOSE: The purpose of the study is to evaluate the clinical safety and effectiveness of the Denali (Bard, Tempe, Arizona) retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS: In this retrospective study, authors reviewed the data of Denali IVC filters placed at their institution between 2013 and 2015. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. The frequency of post filter pulmonary embolism (PE) and filter-related complications was assessed. RESULTS: Denali filters were placed in 87 patients (47 males; mean age: 56 years). Twenty patients presented with PE, 45 with deep vein thrombosis (DVT), and 21 with both PE and DVT, 1 filter was placed prophylactically before surgery. Indications for filter placement included contraindications to anticoagulation (AC; n = 80), failure of AC (n = 4), and complications of AC (n = 3). No patients had PE on follow-up imaging after filter placement. Retrieval was attempted in 31 patients after a mean period of 125 days (range: 34-324 days). The filter was successfully removed in 31 (100%) patients. Follow-up imaging, available in 71 (82%) patients (range: 2-538 days), demonstrated penetration of 15 legs in 5 patients, caval thrombus in 3, 1 resulting in caval occlusion, <15° filter tilt in 5, and no leg fractures or crossed legs. CONCLUSION: The Denali filter is safe during deployment and readily retrievable. The overall safety following deployment is similar to those reported in the literature, and the incidence of filter fractures and migration appears to be less than the previous generation of Bard devices.

Approaching the Practice Quality Improvement Project in Interventional Radiology.

An important component of maintenance of certification and quality improvement in radiology is the practice quality improvement (PQI) project. In this article, the authors describe several methodologies for initiating and completing PQI projects. Furthermore, the authors illustrate several tools that are vital in compiling, analyzing, and presenting data in an easily understandable and reproducible manner. Last, they describe two PQI projects performed in an interventional radiology division that have successfully improved the quality of care for patients. Using the DMAIC (define, measure, analyze, improve, control) quality improvement framework, interventional radiology throughput has been increased, to lessen mediport wait times from 43 to 8 days, and mediport infection rates have decreased from more than 2% to less than 0.4%.

Update on treatment of liver metastases: focus on ablation therapies.

There is substantial and growing interest in the use of local therapies to treat patients with metastatic cancer, especially those deemed to have "oligometastatic" disease. Much of the literature to date consists of reports on metastasectomy for liver and lung metastases. Non-surgical minimally or non-invasive treatments including thermal ablation, irreversible electroporation, and high-dose radiation therapy (stereotactic ablative radiation therapy) can also be used in the treatment of primary and secondary tumors, including in the treatment of liver metastases. In this review, we discuss the rationale for using these ablative treatments in the treatment of liver metastases including similarities and differences between them.