Innovative Information Technology-Powered Population Health Care Management Improves Outcomes and Reduces Hospital Readmissions and Emergency Department Visits.

BACKGROUND: Patients with chronic conditions are often the most frequent users of health care. Moreover, adapting to developments in one's illness, understanding how to self-manage a chronic illness, and sharing information between primary care and specialty providers, can be a full-time job for someone with a chronic illness. In response to these challenges, Christiana Care Health System (Wilmington, Delaware) developed Care Link, an information technology (IT)-enhanced care management support to enable populations of patients to achieve better clinical outcomes at lower cost. METHODS: In 2012 Christiana Care received a grant to design a generalizable, scalable, and replicable IT-driven care model that would integrate disparate clinical and registry data generated from routine care to support longitudinal care management for patients with ischemic heart disease. The single-disease care management program was expanded beginning in mid-2015 to serve risk-based models for many diseases and chronic conditions. RESULTS: More than 8,600 patients in several surgical and medical populations, including joint replacement, cervical spine surgery, and congestive heart failure, have been supported by Care Link. For example, preoperative assessment of patients with elective joint replacement to predict post-acute care needs led to an increase in the volume of patients discharged to home with self-care or with home health care by 30%-from 61% to 80%. CONCLUSION: Care Link IT functions can be replicated to address the unique longitudinal care needs of any population. Care Link's next steps are to continue to increase the number of patients served throughout the region and to expand the scope of care management programming.

Emergency department tachypnea predicts transfer to a higher level of care in the first 24 hours after ED admission.

OBJECTIVES: The authors hypothesized that vital sign abnormalities detected in the emergency department (ED) can be used to forecast clinical deterioration occurring within 24 hours of hospital admission. METHODS: This was a retrospective case-control study performed after implementation of a hospitalwide rapid response team (RRT) system. Inclusion criteria for study patients consisted of age > or = 18 years, admission to the general floor though the ED, and RRT activation and subsequent transfer to a higher level of care in the first 24 hours. Control patients were > or =18 years, were admitted to the floor though the ED, never required RRT or transfer to a higher level of care, and were matched to cases by risk of mortality. Multilevel logistic regression was used to model the odds of an adverse outcome as a function of race and sex, respiratory rate (RR), heart rate (HR), and systolic (sBP) and diastolic blood pressure (dBP) at time of transfer from the ED. RESULTS: A total of 74 cases and 246 controls were used. RR (odds ratio [OR] = 2.79 per 10-point change, 95% confidence interval [CI] = 1.41 to 5.51) and to a lesser extent dBP (OR = 0.81, 95% CI = 0.67 to 0.97) contributed significantly to the odds of intensive care unit (ICU) or intermediate care transfer within 24 hours of admission; HR (OR = 1.15, 95% CI = 0.98 to 1.37) did not. CONCLUSIONS: Emergency department RR preceding floor transfer appears to have a significant relationship to the need for ICU or intermediate care transfer in the first 24 hours of hospital admission.

Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group.

BACKGROUND: Few data are available regarding the results of nonoperative treatment of distal biceps ruptures. The present study was designed to assess the outcomes associated with unrepaired distal biceps tendon ruptures. METHODS: Eighteen patients with twenty unrepaired distal biceps tendon ruptures were assessed retrospectively. The median duration of follow-up was thirty-eight months. Sixteen of the eighteen patients were male, and the median age at the time of the injury was fifty years (range, thirty-five to seventy-four years). Supination strength and elbow flexion strength were measured bilaterally, and patient outcomes were assessed with use of the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire. Data were compared with historical controls compiled from six published series of operatively treated patients. RESULTS: The median supination and elbow flexion strengths for the injured arm were 63% (mean, 74%; range, 33% to 162%) and 93% (mean, 88%; range, 58% to 110%) of those for the contralateral arm, compared with values of 92% (mean, 101%; range, 42% to 297%) and 95% (mean, 97%; range, 53% to 191%) for the historical controls that had been treated surgically. The difference between the mean values was significant for supination strength (p = 0.002) but not for flexion strength (p = 0.164). Patients had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively. CONCLUSIONS: Nonoperative treatment of distal biceps tendon ruptures can yield acceptable outcomes with modestly reduced strength, especially supination.

Improving care of the sepsis patient.

BACKGROUND: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. METHODS: In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patient's clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. RESULTS: Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. DISCUSSION: An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.