Kho Amia2008 Demo Final


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Our presentation at AMIA about our regional MRSA collaborative and use of health information technology to share MRSA colonization and infection data electronically.

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  • Infection control is information intensive, we know what to do, but need to do better with getting data to the people that need to know.
  • Bottom line: we have much to learn from our international colleagues
  • The dots represent the home addresses of individuals seen on Indianapolis ED’s.
    For the Indianapolis patient that visits Lake County ED for asthma, their Indianapolis provider currently has little chance of securing encounter information.
    “A Network of Networks”
  • Or via printer on weekends/evenings
  • If there is a use case for breaking down the barriers between healthcare systems in the United States, it’s the indiscriminate spread of infections.
  • Kho Amia2008 Demo Final

    1. 1. An Operational Citywide Electronic Infection Control Network: Results from the First Year Abel Kho MD, MS; Paul Dexter, MD Brad Doebbeling, MD, MSc, Northwestern University, VA HSR&D Center of Excellence, Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, IU School of Medicine, Indianapolis, IN
    2. 2. Outline • The problem with MRSA • The INPC and Informatics infrastructure • Citywide electronic alerts and results to date • Converting alerts into action • Questions
    3. 3. MRSA Background Purpose • MRSA Burden – Over 126,000 persons are infected by MRSA in hospitals annually – ~ 4 MRSA infections per 1,000 hospital discharges – Over 5,000 die as a result of these infections – Over $2.5 billion excess healthcare costs • On average, for each MRSA patient this means: – 9.1 days excess LOS – Over $30,000 in excess cost per case (range $30,000-60,000) – 4% in excess in-hospital mortality • 1/3 patients acquiring MRSA will become infected.
    4. 4. Reservoir for the Spread of Antibiotic Resistant Pathogens • Colonized patients, NOT just infected patients, can transmit AR pathogens to healthcare workers and other patients. Unidentified Colonized Patients • Clinical Cultures + • History of MRSA
    5. 5. Prevalence of Methicillin-Resistance Among S. aure us Infections, Denmark and US, 1960-2004 0 10 20 30 40 50 60 70 1960 1966 1972 1978 1984 1990 1996 2002 %Resistant USA (ICUs) Denmark (BSIs)
    6. 6. Methods to reduce transmission in hospitals: –Hand Hygiene –Barrier Isolation –Active Surveillance
    7. 7. Models of Success • Netherlands, Denmark • Prompt isolation of MRSA positive patients • “Search and Destroy” approach • Surveillance cultures on patients recently hospitalized in other countries • Prevalence of MRSA <1% in the community and hospitalized patients
    8. 8. The Indiana Network for Patient Care (INPC) An operational community wide electronic medical record
    9. 9. INPC – Participants • 11 hospitals from the 5 major Indianapolis hospital systems (95% of inpatient care) • Includes county and state public health departments • Standards based (LOINC, HL7) • More than a billion clinical observations • 13 year old information exchange
    10. 10. RegionalRegional CentralCentral IndianaIndiana HospitalsHospitals (INPC)(INPC)
    11. 11. Consolidating the Silos Global PatientGlobal Patient IndexIndex ConceptConcept DictionaryDictionary Global ProviderGlobal Provider IndexIndex St FrancisClarian Health Partners Wishard Health Services Community Public Health IUMG PC MMG St Vincent IUMG SC
    12. 12. Preliminary Studies
    13. 13. The Regional Nature of MRSA Admissions • 2006 • 286 unique patients generated 587 admissions (4,335 inpatient days) where receiving hospital unaware of the prior history of MRSA. • An additional 10% of MRSA admissions received by project hospitals over one year and over 3,600 inpatient days without contactisolation. Kho AN, Lemmon L, Commiskey M, Wilson SJ, McDonald CJ. Use of a Regional Health Information Exchange to Detect Crossover of Patients with MRSA between Urban Hospitals. Journal of the American Medical Informatics Association 2008 15(2):212-216.
    14. 14. Electronic Regional Infection Control Network ERICNet
    15. 15. ERICNet –2004 –Create a shared electronic platform for infection control –Built upon the existing INPC –Would require organizational and individual change
    16. 16. Getting There • Build consensus (bottom up) • Meetings! – Build teams – Designate champions – Listen to feedback from the users (surveys, weekly teleconferences)
    17. 17. Getting There - Informatics • Standardize the MRSA (and VRE) lists from all hospitals in Indianapolis • Create standardized reports and data entry forms • Integrate with workflow
    18. 18. St Francis MRF Concept Dictionary Clarian MRF Community MRF St Vincent MRF Global Patient Index Wishard MRF Wishard Hospital University Hospital Admit
    19. 19. Sample E-mail Alert • From: Date: 08-14-2007 16:32 Subject: %%% INFECTION CONTROL ALERT %%% WISHARD INFECTION CONTROL ALERT: Patient 0000005-2 was admitted on 14-Aug-07 01:22 PM to Hospital: Location: ERSR on Unit: ERSR Alert based on data from your institution. Please login to INPC CareWeb for further details. url:
    20. 20. Results to Date
    21. 21. Tracking MRSA • > 17,000 MRSA cases • As of 2007, 3558 cases of skin and soft tissue infections – CA-MRSA? – 37% AA – Increasing year on year • 5705 Alerts to date
    22. 22. Careweb Alerts 0 50 100 150 200 250 300 350 400 450 May-07 June July August September October November December Jan-08 February March April May June July August September Alerts
    23. 23. Number of Admissions Number of Unique Patients 1 2560 2 669 3 229 4 96 5 43 6 18 7 15 8 4 9 9 10 5 11 5 12 2 16 1 21 1 29 1 Total 3658
    24. 24. % MRSA admissions originating from an outside hospital 0 5 10 15 20 25 30 Retrospective Estimate Six Months of Alerts 18 Months of Alerts Months %
    25. 25. Usability Survey • 12/20 ICPs responded • Useful? 100% • Average alerts per day: 5 • Average new cases: 2.2 • Average 4.4 cases entered per day • 2.3 minutes to enter a new case • Spend 1-2 hours per week entering or editing cases
    26. 26. Things we should improve • Automate capture of new cases from laboratory • Avoid double entry of MRSA cases into into their own system • Improve Reporting Tools • Increase amount of information in alerts • Deliver alerts to Admissions office as well
    27. 27. What do we do with this information?
    28. 28. AHRQ ACTION Contract Implementation  “Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria (MRSA)”  AHRQ funded Indiana ACTION Team effort over 18 months through the ACTION collaborative funding mechanism  Our interventions are based on the Pittsburgh model as specified by AHRQ:  conduct active surveillance of all incoming pts. in ICUs  improve rates of contact isolation  Improve hand hygiene rates
    29. 29. Conceptual Framework and Strategy • Interdisciplinary Research & Ops Teams • Clinicians, Health Services Researchers, Engineering/Technology Faculty, Purdue Communication faculty/students, Organizational Psychologists, Informaticists • Partnership with selected Hospital Clinical Staff • Integrated Lean/Positive Deviance Approach: • Identification of solutions from within, bottom up • Leadership support and buy-in • Standardization where evidence exists or to simplify • Customization to meet local redesign needs
    30. 30. Improvement Cycle Take Action /Develop Future State Process Control Strategy Baseline Current Processes Identify Operational Barriers Define/ Discovery Process Observation Worksheet Spaghetti Diagram Lean Tools Process Map Check sheet Process Control Plan Voice of the Customer PD Discovery Session PDSA Cycles
    31. 31. Health Systems Involved • Two ICU units in 3 original hospital systems – St. Francis (two ICUs in South Hospital) – Clarian (Methodist and University Hospital) – Community (Community East and Heart Hospital) • Early success encouraged 3 remaining systems to join the project – Wishard (two ICUs) – VA Medical Center (housewide) – St. Vincent's (two ICUs in north facility)
    32. 32. System Redesign • Our health care engineers partner with and train front-line workers to use lean-six sigma and positive deviance approaches • Focus on coaching front-line staff teams to lead instituting systems changes to systematize processes and sustain practices. • Emphasize regular measurement and feedback of adherence to enhance adoption. • Weekly Meeting of all hospital teams to identify barriers & facilitators, review and reinforce progress, share best practices, strategize about spread and solutions.
    33. 33. Evaluation and Results • Range of 3-22% (monthly average) incoming patients colonized with MRSA on study units • The number of conversions varied across study units (4 23 during study period) • Variability in pre-intervention Nosocomial infection rates across participating hospitals (.015  .025) • Greater variability in pre-intervention study unit MRSA infection data (.008  .074)
    34. 34. Admission Culture Compliance for Study Units 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 aug-07 Sep-07 Oct-07 Nov-07 Dec-2007 %complianceagainstprotocol A-1 A-2 B-1 C-1 C-2 W-1 Average of % of patients receiving admission cx Hosp-unit
    35. 35. Statistical Analysis • Infection data from 5 hospitals were collected at monthly time intervals 12 months before and after implementation • A Poisson generalized estimating equation (GEE) model to evaluate the impact of the intervention bundle. • Expected mean number of MRSA cases per 30 day time period and corresponding 95% Cis for pre-, intervention intervals. • GEE estimation procedures to adjust for the covariance structure of the repeated observations. • Interaction terms to account for hospital, health system and unit differences in the effect of the intervention bundle.
    36. 36. MRSA Infection Results • An overall decrease in the number of MRSA cases following the intervention bundle. • For each of the models, initial parameter estimates suggest a statistically significant effect of the intervention (p=0.06). • After adjusting for the covariance structure of the repeated observations, the significance is even greater (p<0.01).
    37. 37. Lessons Learned-- Implementation • Importance of buy-in from highest institutional levels crucial. • Value of engaging frontline staff in the process of planning and implementation. • Enthusiasm builds from within because redesign teams own it! • Use of Lean Six Sigma tools, especially process mapping. • Data collection tool, and resources to manage and analyze the data crucial.
    38. 38. Lessons Learned--Research  Our proposed data collection too intensive for most community hospitals  Need to adequately staff data collection and observation of intervention bundle compliance  Need a better electronic data collection infrastructure relating to compliance and outcome data  Little time for paper writing and dissemination projects (Hazard of short time lines for funding)
    39. 39. Conclusions • Hospitals do not operate in a vacuum • Infections do not care what health care system you receive most of your care • Regional / Coordinated efforts • Standardized approach to data collection and intervention
    40. 40. Future Work • Ongoing funding from AHRQ / CDC 1. Study ambulatory care factors which determine what patients are admitted with invasive CA- MRSA infections 2. Disseminate best practices to control HA- MRSA • Automate capture and reporting of culture results and intervention compliance
    41. 41. Acknowledgement s • Agency for Healthcare Research and Quality (HHSA290200600013 Task order #1) • Larry Lemmon • Shahid Khokhar • Shawn Hoke • Jamie Workman- Germann, MS • Doub Webb, MD • Laurie Fish, RN • Claire Rumpke, RN • Loretta Marsh, RN • Sandra Benson, RN • Marie Comminsky, RN • Diana Greathouse, RN • Kim McCoy, MS • Mahesh Merchant, PhD • Mindy Flanagan, PhD