Bracing for the Storm: One Health Care System's Planning for the COVID-19 Surge.

PROBLEM: University of Washington Medicine (UW Medicine), an academic health system in Washington State, was at the epicenter of the first outbreak of the COVID-19 pandemic in the United States. The extent of emergency activation needed to adequately respond to this global pandemic was not immediately known, as the evolving situation differed significantly from any past disaster response preparations in that there was potential for exponential growth of infection, unproven mitigation strategies, serious risk to health care workers, and inadequate supply chains for critical equipment. APPROACH: The rapid transition of the UW Medicine system to account for projected COVID-19 and usual patient care, while balancing patient and staff safety and conservation of resources, represents an example of an adaptive disaster response. KEY INSIGHTS: Although our organization's ability to meet the needs of the public was uncertain, we planned and implemented changes to space, supply management, and staffing plans to meet the influx of patients across our clinical entities. The surge management plan called for specific actions to be implemented based on the level of activity. This article describes the approach taken by UW Medicine as we braced for the storm.

Upper extremity deep vein thrombosis in hospitalized patients: a descriptive study.

Increasingly, there is a focus on the prevention of hospital-acquired conditions including venous thromboembolism. Many studies have evaluated pulmonary embolism and lower extremity deep vein thrombosis, but less is known about upper extremity deep vein thrombosis (UEDVT) in hospitalized patients. The objective of this study was to describe UEDVT incidence, associated risks, outcomes, and management in our institution. Using an information technology tool, we reviewed records of all symptomatic adult inpatients diagnosed with UEDVT at an academic tertiary center between September 2011 and November 2012. Fifty inpatients were diagnosed with 76 UEDVTs. Their mean age was 49 years; 70% were men. Sixteen percent had a history of venous thromboembolism; 20% had a history of malignancy. The mean length of stay (LOS) was 24.6 days (range, 2-91 days); 50% were transferred from outside hospitals. Thirty-eight percent of UEDVTs were in internal jugular veins, 21% in axillary veins, and 25% in brachial veins. Forty-four percent of patients had UEDVT associated with central venous catheters (CVCs). During hospitalization, 78% were fully anticoagulated; 75% of survivors at discharge. Only 38% were discharged to self-care; 10% died during hospitalization. Patients with UEDVT were more likely to have CVCs, malignancy, and severe infection. Many patients were transferred critically ill with prolonged LOS and high in-hospital mortality. Most UEDVTs were treated even in the absence of concurrent lower extremity deep vein thrombosis or pulmonary embolism. Additional research is needed to modify risks and optimize outcomes. Journal of Hospital Medicine 2014;9:48-53. © 2013 Society of Hospital Medicine.

Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE).

Quality improvement (QI) and patient safety (PS) are essential competencies in residency training; however, the most effective means to engage physicians remains unclear. The authors surveyed all medicine and surgery physicians at their institution to describe QI/PS practices and concurrently implemented the Advocate for Clinical Education (ACE) program to determine if a physician-centered program in the context of educational structures and at the point of care improved performance. The ACE rounded with medicine and surgery teams and provided individual and team-level education and feedback targeting 4 domains: professionalism, infection control, interpreter use, and pain assessment. In a pilot, the ACE observed 2862 physician-patient interactions and 178 physicians. Self-reported compliance often was greater than the behaviors observed. Following ACE implementation, observed professionalism behaviors trended toward improvement; infection control also improved. Physicians were highly satisfied with the program. The ACE initiative is one coaching/feedback model for engaging residents in QI/PS that may warrant further study.

Recent Trends in Adherence to Secondary Prevention Guidelines for Patients Undergoing Coronary Revascularization in Washington State: An Analysis of the Clinical Outcomes Assessment Program (COAP) Registry.

BACKGROUND: Previous studies indicated that patients undergoing coronary artery bypass graft (CABG) surgery are less likely to receive guideline-based secondary prevention therapy than are those undergoing percutaneous coronary intervention (PCI) after an acute myocardial infarction. We aimed to evaluate whether these differences have persisted after the implementation of public reporting of hospital metrics. METHODS AND RESULTS: The Clinical Outcomes Assessment Program (COAP) database was analyzed retrospectively to evaluate adherence to secondary prevention guidelines at discharge in patients who underwent coronary revascularization after an acute ST-elevation myocardial infarction in Washington State. From 2004 to 2007, 9260 patients received PCI and 692 underwent CABG for this indication. Measures evaluated included prescription of aspirin, ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, or lipid-lowering medications; cardiac rehabilitation referral; and smoking-cessation counseling. Composite adherence was lower for CABG than for PCI patients during the period studied (79.6% versus 89.7%, P<0.01). Compared to patients who underwent CABG, patients who underwent PCI were more likely to receive each of the pharmacological therapies. There was no statistical difference in smoking-cessation counseling (91.7% versus 90.3%, P=0.63), and CABG patients were more likely to receive referral for cardiac rehabilitation (70.9% versus 48.3%, P<0.01). Adherence rates improved over time among both groups, with no significant difference in composite adherence in 2006 (85.6% versus 87.6%, P=0.36). CONCLUSIONS: Rates of guideline-based secondary prevention adherence in patients with ST-elevation myocardial infarction who underwent CABG surgery have been improving steadily in Washington State. The improvement possibly is associated with the implementation of public reporting of quality measures.

Using an electronic medical record tool to improve pneumococcal screening and vaccination rates for older patients admitted with community-acquired pneumonia.

An electronic medical record tool was developed that determines if a patient meets criteria for screening for the vaccine; it then poses a series of screening questions. Use of the tool has improved performance on pneumococcal vaccination from 44% to more than 90%, with an increase in vaccine units of 305%.

Adherence to guideline-directed venous thromboembolism prophylaxis among medical and surgical inpatients at 33 academic medical centers in the United States.

This study's purpose was to describe compliance with established venous thromboembolism (VTE) prophylaxis guidelines in medical and surgical inpatients at US academic medical centers (AMCs). Data were collected for a 2007 University HealthSystem Consortium Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Benchmarking Project that explored VTE in AMCs. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. A total of 33 AMCs from 30 states participated. In all, 48% of patients received guideline-directed prophylaxis-59% were medical and 41% were surgical patients. VTE history was more common among medical patients with guideline-directed prophylaxis. Surgical patients admitted from the emergency department and with higher illness severity were more likely to receive appropriate prophylaxis. Despite guidelines, VTE prophylaxis remains underutilized in these US AMCs, particularly among surgical patients. Because AMCs provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.

Validation of the "HAMP" mapping algorithm: a tool for long-term trauma research studies in the conversion of AIS 2005 to AIS 98.

BACKGROUND: There are significant changes in the abbreviated injury scale (AIS) 2005 system, which make it impractical to compare patients coded in AIS version 98 with patients coded in AIS version 2005. METHODS: Harborview Medical Center created a computer algorithm "Harborview AIS Mapping Program (HAMP)" to automatically convert AIS 2005 to AIS 98 injury codes. The mapping was validated using 6 months of double-coded patient injury records from a Level I Trauma Center. HAMP was used to determine how closely individual AIS and injury severity scores (ISS) were converted from AIS 2005 to AIS 98 versions. The kappa statistic was used to measure the agreement between manually determined codes and HAMP-derived codes. RESULTS: Seven hundred forty-nine patient records were used for validation. For the conversion of AIS codes, the measure of agreement between HAMP and manually determined codes was [kappa] = 0.84 (95% confidence interval, 0.82-0.86). The algorithm errors were smaller in magnitude than the manually determined coding errors. For the conversion of ISS, the agreement between HAMP versus manually determined ISS was [kappa] = 0.81 (95% confidence interval, 0.78-0.84). CONCLUSION: The HAMP algorithm successfully converted injuries coded in AIS 2005 to AIS 98. This algorithm will be useful when comparing trauma patient clinical data across populations coded in different versions, especially for longitudinal studies.

A descriptive case series of patients with end-stage liver disease hospitalized with variceal bleeding who received pharmacologic venous thromboembolism prophylaxis.

BACKGROUND: It is unknown whether venous thromboembolism prophylaxis (VTEP) should be utilized in hospitalized patients with end-stage liver disease (ESLD), particularly in those admitted with variceal bleeding. OBJECTIVE: We sought to describe a cohort of patients who received pharmacologic VTEP, specifically identifying the occurrence of rebleeding. DESIGN: Descriptive case series. SETTING/PATIENTS: All adult patients with ESLD admitted to an urban county teaching hospital over three years with variceal bleeding who received pharmacologic VTEP during hospitalization. RESULTS: A total of 22 patients with ESLD and variceal bleeding received pharmacologic VTEP. Only 1 patient rebled after initiation of VTEP; 2 patients were diagnosed with lower extremity deep venous thrombosis while on VTEP including the 1 patient who rebled. CONCLUSIONS: VTEP was associated with an unexpectedly low incidence of recurrent bleeding in patients with ESLD and variceal bleeding. Further study may be warranted.

Translating a multifactorial fall prevention intervention into practice: a controlled evaluation of a fall prevention clinic.

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall-related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.

Improving insulin ordering safely: the development of an inpatient glycemic control program.

This report describes a Glycemic Control Program instituted at an academic regional level-one trauma center. Key interventions included: 1) development of a subcutaneous insulin physician order set, 2) use of a real-time data report to identify patients with out-of-range glucoses, and 3) implementation of a clinical intervention team. Over four years 18,087 patients admitted to non-critical care wards met our criteria as dysglycemic patients. In this population, glycemic control interventions were associated with increased basal and decreased sliding scale insulin ordering. No decrease was observed in the percent of patients experiencing hperglycemia. Hypoglycemia did decline after the interventions (4.3% to 3.6%; p = 0.003). Distinguishing characteristics of this Glycemic Control Program include the use of real-time data to identify patients with out-of-range glucoses and the employment of a single clinician to cover all non-critical care floors.

The role of out-of-hospital cardiac arrest in predicting hospital mortality for percutaneous coronary interventions in the Clinical Outcomes Assessment Program.

Published mortality models for percutaneous coronary intervention (PCI), including the Clinical Outcomes Assessment Program (COAP) model, have not considered the effect of out-ofhospital cardiac arrest. The primary objective of this study was to determine if the inclusion of out-of-hospital cardiac arrest altered the COAP mortality model for PCI. The COAP PCI database contains extensive demographic, clinical, procedural and outcome information, including out-of-hospital cardiac arrest, which was added to the data collection form in 2006. This study included 15,586 consecutive PCIs performed in 31 Washington State hospitals in 2006. Using development and test sets, the existing COAP PCI logistic regression mortality model was examined to assess the effect of out-of-hospital arrest on in-hospital mortality. Overall, 2% of individuals undergoing PCI had cardiac arrest prior to hospital arrival. Among 8 hospitals with PCI volumes < 120 cases per year, 4 had cardiac arrest volumes that exceeded 10% of total volume, whereas none of the centers with > 120 cases per year did. In-hospital mortality was 19% in the arrest group and was 1.0% in remaining procedures (p < 0.0001). In the new multivariate model, out-of-hospital cardiac arrest was highly associated with mortality (odds ratio = 5.50; 95% confidence interval [CI] = 3.28-9.25). When evaluated in the test set, the new model had excellent discrimination (c-statistic = 0.89; 95% CI = 0.85-0.93). Out-of-hospital cardiac arrest is an important determinant of risk-adjusted in-hospital mortality for PCI, particularly for hospitals with low volumes and relatively high volumes of cardiac arrest cases.

Effects of a statewide physician-led quality-improvement program on the quality of cardiac care.

BACKGROUND: Several states have implemented mandatory public reporting of outcomes of cardiac revascularization procedures. Washington is the first to develop a nonmandatory, physician-led reporting program with public accountability and universal hospital participation. The purpose of this study was to determine whether quality improvement interventions resulted in the correction of data deficiencies and performance outliers for cardiac revascularization procedures. METHODS: From 1999 through 2003, there were 18 hospitals with coronary bypass surgery and interventional cardiology programs and 12 with only the latter. All patients > or =18 years undergoing 24372 isolated coronary bypass surgeries and 59,656 percutaneous coronary interventions were included. After 1999 to 2001 data were analyzed in early 2002, the Clinical Outcomes Assessment Program implemented a 6-step quality-improvement intervention to measure and remeasure data quality, process compliance, and performance. RESULTS: In 2003, 4 of the 18 surgery programs had 1 statistical outlier with respect to 4 performance measures, whereas 2 of 30 coronary intervention programs were mortality outliers. For bypass surgery, all programs maintained full compliance with program standards by adhering to timely and reliable submission of data, developing plans to address performance outliers, and demonstrating that outlier status did not persist from baseline to remeasurement. For coronary interventions, 1 program was a persistent outlier for mortality in 2002 and 2003. CONCLUSIONS: The Clinical Outcomes Assessment Program has successfully monitored cardiac care patterns in Washington State over a 5-year period. Most hospitals that perform coronary revascularization procedures meet acceptable performance standards.

Predictors of hospital outcomes after percutaneous coronary intervention in the community.

BACKGROUND: It is not well established to what degree advances have been adopted into contemporary percutaneous coronary intervention (PCI) practice in the community and what effect they have on the short-term outcomes of in-hospital mortality and length of stay. METHODS: We analyzed a prospectively-collected, statewide registry that includes consecutive patients undergoing isolated PCI to determine predictors of in-hospital outcomes after the first PCI performed in the community. Multivariable logistic regression analysis was used to determine factors associated with in-hospital mortality after first PCI. RESULTS: Between January 1, 1999 and December 31, 2000 there were a total of 12,920 cases of first PCI performed, 4535 (35.1%) of which were for acute myocardial infarction (MI). Stents and glycoprotein (GP) IIb/IIIa inhibitors were used in 89.6% and 70.0%, respectively, of all cases. In-hospital mortality was 1.8%. Length of hospital stay was 1 (1, 3) days [median (interquartile range)] in the absence of acute MI, and 3 (2, 4) days after acute MI. After acute MI, peri-procedure GP IIb/IIIa inhibitor use [adjusted OR 0.41 (95% CI 0.26, 0.63)] and stenting [adjusted OR 0.61 (95% CI 0.37, 0.996)] were the only factors positively associated with freedom from hospital death. CONCLUSIONS: Intracoronary stenting and use of GP IIb/IIIa inhibitors have been well integrated into community practice. The observed in-hospital mortality rate is slightly higher than published in other series, but likely reflects the significant proportion of acute MI cases being treated aggressively with PCI as the primary therapy.

Health status and social risk correlates of extended length of stay following coronary artery bypass surgery.

BACKGROUND: Preoperative severity of illness in patients undergoing coronary artery bypass grafting (CABG) surgery is a major determinant of clinical postoperative outcomes and surgical length of stay (SLOS). Preoperative patient reported health status and social risk have not been quantified as predictors of SLOS post-CABG. Our hypothesis was that poorer self-reported health and greater social risk, as measured by standardized instruments, are significantly associated with extended SLOS defined as greater than or equal to 7 days. METHODS: In the pilot phase of the Washington State Clinical Outcomes Assessment Program (COAP) patients in a case series between 1995 and 1996 at all hospitals with a cardiac surgery program were administered preoperative SF-36 and Seattle Angina Questionnaires (SAQ) in addition to the collection of prospective clinical data with Society of Thoracic Surgeons' compatible definitions (n = 1073). Factors found significant from bivariate analysis were incorporated into a logistic regression model to assess relative association with extended SLOS (>/= 7 days). RESULTS: The final model included the following elements in descending order of significance: site, SF-36 health perceptions (HP) scale, social risk factors, age, intraaortic balloon pump, congestive heart failure, comorbidity score more than 2, preoperative days more than 2, emergency operation, prior CABG, and gender. CONCLUSIONS: The HP subscore of the SF-36 and the composite social risk factors score were significantly associated with extended SLOS after controlling for other standard clinical variables. "Hospital site" remained the factor with the greatest variance independent of patient severity of illness.

Predictors of repeat revascularization after nonemergent, first percutaneous coronary intervention in the community.

BACKGROUND: We sought to determine the incidence of and risk factors for repeat revascularization after nonemergent, first percutaneous coronary intervention (PCI) performed in contemporary community practice. METHODS: We analyzed a prospective registry of consecutive patients undergoing isolated PCI in the state of Washington. Multivariate Cox regression analysis was used to determine predictors of repeat revascularization (by PCI or bypass surgery) within 1 year after first PCI. RESULTS: Between January 1, 1999, and December 31, 1999, there were 3571 nonemergent first PCIs, 87.7% of which involved stent placement. Repeat revascularization occurred in 577 (16.2%) patients. Repeat revascularization was predicted by multivessel disease (hazard ratio [HR] 1.36, 95% CI 1.12-1.66), stable versus no angina (HR 1.27, 95% CI 1.03-1.57), and maximum stent length used (per 1 mm longer: HR 1.01, 95% CI 1.002-1.02), while prior myocardial infarction (HR 0.77, 95% CI 0.62-0.96) and creatinine >1.2 mg/dL (HR 0.74, 95% CI 0.56-0.98) were associated with lower risk of repeat revascularization. Diabetes was a significant predictor only when the outcome was limited to revascularization by coronary artery bypass surgery (HR 1.52, 95% CI 1.03-2.23). Although glycoprotein IIb/IIIa inhibitor use was a significant univariate predictor of freedom from early repeat revascularization (within 60 days after first PCI), after controlling for potential confounders, it was no longer significant. CONCLUSIONS: In this contemporary, community-based registry of patients undergoing nonemergent first PCI, clinical practice and outcomes are consistent with evidence from clinical trials and previous controlled studies. Results from controlled studies may reasonably be extrapolated to such a community setting.

The effect of left internal mammary artery utilization on short-term outcomes after coronary revascularization.

BACKGROUND: The purpose of this study was to determine whether use of the left internal mammary artery (LIMA) during coronary revascularization influences short-term morbidity in all patients undergoing revascularization, as well as in patients over the age of 75 years, female patients, and patients with diabetes. The study also explored variability in the utilization of LIMA grafts across an entire state. METHODS: Using the Clinical Outcomes Assessment Program (COAP) of the state of Washington, procedural outcomes were compared for patients receiving and patients not receiving LIMA grafts as part of revascularization procedures from January 1, 1999 to December 31, 2000. Mortality and major complications were examined, both as unadjusted rates and after adjusting for baseline patient risk factors. RESULTS: A total of 16 centers performed 8,797 nonemergent coronary artery revascularizations, including 81.7% with LIMA grafts. The use of a LIMA graft was associated with a significantly lower mortality (3.7% No LIMA vs 1.6% LIMA), as well as decreases in ventricular arrhythmias, need for postoperative dialysis, need for transfusions, ventilator dependence, and length of hospital stay. These trends were true for the population as a whole as well as for all subgroups analyzed, and they persisted after correcting for differences in comorbid conditions. In addition, there was wide variability in the use of LIMA grafts from center to center in the state. CONCLUSIONS: The use of LIMA grafts for coronary revascularization is associated with decreased mortality and morbidity. Despite these advantages, there is great variability in its application across the state of Washington.

Use of off-pump and on-pump CABG strategies in current clinical practice: the Clinical Outcomes Assessment Program of the state of Washington.

BACKGROUND: The purpose of this study is to assess clinical outcomes and regional differences in the use of on-pump and off-pump CABG in current clinical practice. METHODS: Between January 1, 1999, and December 31, 2000, there were 10,429 CABG procedures performed in 16 Washington state hospitals, all of which participate in Clinical Outcomes Assessment Program database. This analysis excluded patients with a history of prior CABG as well as those who underwent emergent surgery. After applying these exclusion criteria, 8402 patients (7169 on-pump and 1233 off-pump CABG procedures) were evaluated and presented as both unadjusted and risk-adjusted outcomes. OUTCOMES: Off-pump CABG constituted 14.7% of all surgical revascularization procedures. These varied enormously among individual centers from an incidence of 0% to 68.9%. The use of off-pump CABG was not associated with a decreased risk of risk-adjusted hospital mortality or stroke, but was associated with a reduction in hospital stay > 7 days (OR 0.62, CI 0.51-0.76), ventilator > 24 hours (OR 0.52, CI 0.34-0.81), dialysis (OR 0.34, CI 0.14-0.86), and RBC transfusion (OR 0.5, CI 0.40-0.61). CONCLUSIONS: Despite its highly variable use, off-pump CABG seems to be judiciously used in current clinical practice in the State of Washington and is associated with a decrease in morbidity in appropriately selected patients.

Adjusting for patient differences in predicting hospital mortality for percutaneous coronary interventions in the Clinical Outcomes Assessment Program.

BACKGROUND: The Clinical Outcomes Assessment Program (COAP) is a coordinated quality improvement program for percutaneous coronary interventions (PCIs) performed in Washington State hospitals. This study describes the development and testing of models for predicting hospital mortality in patients undergoing PCI. METHODS: The COAP PCI database contains extensive demographic, medical history, and procedural information. This study included 19,358 consecutive PCIs performed in 27 Washington hospitals in 1999 and 2000. The study population was randomly assigned to development (n = 11,591) and test (n = 7614) sets. Logistic regression mortality models were run in the development set and evaluated in the test set. RESULTS: The test and development sets were similar in demographic, medical history, and procedural characteristics. The overall hospital mortality rate was 1.6% and was similar in the test and development sets. By means of stepwise logistic regression analysis, cardiogenic shock, age, nonelective priority, elevated creatinine level, ejection fraction, number of diseased vessels, myocardial infarction <24 hours from admission, history of chronic obstructive pulmonary disease, male sex, history of peripheral vascular disease, history of PCI, and history of congestive heart failure were identified as predictors of hospital mortality. When applied to the test set, this model had excellent discrimination (c statistic = 0.87, 95% CI = 0.84-0.90). The model was also evaluated in the Northern New England PCI Registry, with very good results (c statistic = 0.85). CONCLUSION: Developing risk-adjusted models of mortality and other outcomes is an essential part of the quality improvement process for cardiac revascularization procedures. Because of the rapidly changing nature of PCI, modification of these models in the years to come will be required.