Early Expected Discharge Date Accuracy During Hospitalization: A Multivariable Analysis

INTRODUCTION

Accurate estimation of an expected discharge date (EDD) early during hospitalization impacts clinical operations and discharge planning.

METHODS

We conducted a retrospective study of patients discharged from six general medicine units at an academic medical center in Boston, MA from January 2017 to June 2018. We retrieved all EDD entries and patient, encounter, unit, and provider data from the electronic health record (EHR), and public weather data. We excluded patients who expired, discharged against medical advice, or lacked an EDD within the first 24 h of hospitalization. We used generalized estimating equations in a multivariable logistic regression analysis to model early EDD accuracy (an accurate EDD entered within 24 h of admission), adjusting for all covariates and clustering by patient. We similarly constructed a secondary multivariable model using covariates present upon admission alone.

RESULTS

Of 3917 eligible hospitalizations, 890 (22.7%) had at least one accurate early EDD entry. Factors significantly positively associated (OR > 1) with an accurate early EDD included clinician-entered EDD, admit day and discharge day during the work week, and teaching clinical units. Factors significantly negatively associated (OR < 1) with an accurate early EDD included Elixhauser Comorbidity Index ≥ 11 and length of stay of two or more days. C-statistics for the primary and secondary multivariable models were 0.75 and 0.60, respectively.

CONCLUSIONS

EDDs entered within the first 24 h of admission were often inaccurate. While several variables from the EHR were associated with accurate early EDD entries, few would be useful for prospective prediction.

Lessons Learned in Implementing a Chronic Opioid Therapy Management System

OBJECTIVES

Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization.

METHODS

Using iterative improvement lifecycles and systems engineering principles, we developed a risk-based workflow model for patients on chronic opioids. Two key safe opioid use process metrics-percent of patients with recent opioid treatment agreements and urine drug tests-were identified, and processes to improve these measures were designed, tested, and implemented. Focus groups were conducted after the conclusion of implementation, with barriers and lessons learned identified via thematic analysis.

RESULTS

Initial surveys revealed a lack of knowledge regarding resources available to patients and prescribers in the primary care clinic. In addition, 18 clinicians (69%) reported largely "inheriting" (rather than initiating) their chronic opioid therapy patients. We tracked 68 patients over a 4-year period. Although process measures improved, full adherence was not achieved for the entire population. Barriers included team structure, the evolving opioid environment, and surveillance challenges, along with disruptions resulting from the 2019 novel coronavirus.

CONCLUSIONS

Safe primary care opioid prescribing requires ongoing monitoring and management in a complex environment. The application of a risk-based approach is possible but requires adaptability and redundancies to be reliable.

Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation

OBJECTIVE

To evaluate the effect of electronic health record (EHR)-integrated digital health tools comprised of a checklist and video on transitions-of-care outcomes for patients preparing for discharge.

MATERIALS AND METHODS

English-speaking, general medicine patients (>18 years) hospitalized at least 24 hours at an academic medical center in Boston, MA were enrolled before and after implementation. A structured checklist and video were administered on a mobile device via a patient portal or web-based survey at least 24 hours prior to anticipated discharge. Checklist responses were available for clinicians to review in real time via an EHR-integrated safety dashboard. The primary outcome was patient activation at discharge assessed by patient activation (PAM)-13. Secondary outcomes included postdischarge patient activation, hospital operational metrics, healthcare resource utilization assessed by 30-day follow-up calls and administrative data and change in patient activation from discharge to 30 days postdischarge.

RESULTS

Of 673 patients approached, 484 (71.9%) enrolled. The proportion of activated patients (PAM level 3 or 4) at discharge was nonsignificantly higher for the 234 postimplementation compared with the 245 preimplementation participants (59.8% vs 56.7%, adjusted OR 1.23 [0.38, 3.96], P = .73). Postimplementation participants reported 3.75 (3.02) concerns via the checklist. Mean length of stay was significantly higher for postimplementation compared with preimplementation participants (10.13 vs 6.21, P < .01). While there was no effect on postdischarge outcomes, there was a nonsignificant decrease in change in patient activation within participants from pre- to postimplementation (adjusted difference-in-difference of -16.1% (9.6), P = .09).

CONCLUSIONS

EHR-integrated digital health tools to prepare patients for discharge did not significantly increase patient activation and was associated with a longer length of stay. While issues uncovered by the checklist may have encouraged patients to inquire about their discharge preparedness, other factors associated with patient activation and length of stay may explain our observations. We offer insights for using PAM-13 in context of real-world health-IT implementations.

TRIAL REGISTRATION

NIH US National Library of Medicine, NCT03116074, clinicaltrials.gov.

Assessing the cognitive and work load of an inpatient safety dashboard in the context of opioid management

For health information technology to realize its potential to improve flow, care, and patient safety, applications should be intuitive to use and burden neutral for frontline clinicians. We assessed the impact of a patient safety dashboard on clinician cognitive and work load within a simulated information-seeking task for safe inpatient opioid medication management. Compared to use of an electronic health record for the same task, the dashboard was associated with significantly reduced time on task, mouse clicks, and mouse movement (each p < 0.001), with no significant increases in cognitive load nor task inaccuracy. Cognitive burden was higher for users with less experience, possibly partly attributable to usability issues identified during this study. Findings underscore the importance of assessing the usability, cognitive, and work load analysis during the design and implementation of health information technology applications.

Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study

BACKGROUND

Poor discharge preparation during hospitalization may lead to adverse events after discharge. Checklists and videos that systematically engage patients in preparing for discharge have the potential to improve safety, especially when integrated into clinician workflow via the electronic health record (EHR).

OBJECTIVE

This study aims to evaluate the implementation of a suite of digital health tools integrated with the EHR to engage hospitalized patients, caregivers, and their care team in preparing for discharge.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify pertinent research questions related to implementation. We iteratively refined patient and clinician-facing intervention components using a participatory process involving end users and institutional stakeholders. The intervention was implemented at a large academic medical center from December 2017 to July 2018. Patients who agreed to participate were coached to watch a discharge video, complete a checklist assessing discharge readiness, and request postdischarge text messaging with a physician 24 to 48 hours before their expected discharge date, which was displayed via a patient portal and bedside display. Clinicians could view concerns reported by patients based on their checklist responses in real time via a safety dashboard integrated with the EHR and choose to open a secure messaging thread with the patient for up to 7 days after discharge. We used mixed methods to evaluate our implementation experience.

RESULTS

Of 752 patient admissions, 510 (67.8%) patients or caregivers participated: 416 (55.3%) watched the video and completed the checklist, and 94 (12.5%) completed the checklist alone. On average, 4.24 concerns were reported per each of the 510 checklist submissions, most commonly about medications (664/2164, 30.7%) and follow-up (656/2164, 30.3%). Of the 510 completed checklists, a member of the care team accessed the safety dashboard to view 210 (41.2%) patient-reported concerns. For 422 patient admissions where postdischarge messaging was available, 141 (33.4%) patients requested this service; of these, a physician initiated secure messaging for 3 (2.1%) discharges. Most patient survey participants perceived that the intervention promoted self-management and communication with their care team. Patient interview participants endorsed gaps in communication with their care team and thought that the video and checklist would be useful closer toward discharge. Clinicians participating in focus groups perceived the value for patients but suggested that low awareness and variable workflow regarding the intervention, lack of technical optimization, and inconsistent clinician leadership limited the use of clinician-facing components.

CONCLUSIONS

A suite of EHR-integrated digital health tools to engage patients, caregivers, and clinicians in discharge preparation during hospitalization was feasible, acceptable, and valuable; however, important challenges were identified during implementation. We offer strategies to address implementation barriers and promote adoption of these tools.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03116074; https://clinicaltrials.gov/ct2/show/NCT03116074.

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center

OBJECTIVE

The objective of this paper is to share challenges, recommendations, and lessons learned regarding the development and implementation of a Patient Safety Learning Laboratory (PSLL) project, an innovative and complex intervention comprised of a suite of Health Information Technology (HIT) tools integrated with a newly implemented Electronic Health Record (EHR) vendor system in the acute care setting at a large academic center.

MATERIALS AND METHODS

The PSLL Administrative Core engaged stakeholders and study personnel throughout all phases of the project: problem analysis, design, development, implementation, and evaluation. Implementation challenges and recommendations were derived from direct observations and the collective experience of PSLL study personnel.

RESULTS

The PSLL intervention was implemented on 12 inpatient units during the 18-month study period, potentially impacting 12,628 patient admissions. Challenges to implementation included stakeholder engagement, project scope/complexity, technology/governance, and team structure. Recommendations to address each of these challenges were generated, some enacted during the trial, others as lessons learned for future iterative refinements of the intervention and its implementation.

CONCLUSION

Designing, implementing, and evaluating a suite of tools integrated within a vendor EHR to improve patient safety has a variety of challenges. Keys to success include continuous stakeholder engagement, involvement of systems and human factors engineers within a multidisciplinary team, an iterative approach to user-centered design, and a willingness to think outside of current workflows and processes to change health system culture around adverse event prevention.

Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR

BACKGROUND

Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems.

OBJECTIVE

This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation.

METHODS

The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption.

RESULTS

The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88).

CONCLUSION

This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.

Acute Care Patient Portal Intervention: Portal Use and Patient Activation

Background

Patient-facing health information technology (HIT) tools, such as patient portals, are recognized as a potential mechanism to facilitate patient engagement and patient-centered care, yet the use of these tools remains limited in the hospital setting. Although research in this area is growing, it is unclear how the use of acute care patient portals might affect outcomes, such as patient activation.

Objective

The aim of this study was to describe the use of an acute care patient portal and investigate its association with patient and care partner activation in the hospital setting.

Methods

We implemented an acute care patient portal on 6 acute care units over an 18-month period. We investigated the characteristics of the users (patients and their care partners) of the patient portal, as well as their use of the portal. This included the number of visits to each page, the number of days used, the length of the user’s access period, and the average percent of days used during the access period. Patient and care partner activation was assessed using the short form of the patient activation measure (PAM-13) and the caregiver patient activation measure (CG-PAM). Comparisons of the activation scores were performed using propensity weighting and robust weighted linear regression.

Results

Of the 2974 randomly sampled patients, 59.01% (1755/2974) agreed to use the acute care patient portal. Acute care patient portal enrollees were younger, less sick, less likely to have Medicare as their insurer, and more likely to use the Partners Healthcare enterprise ambulatory patient portal (Patient Gateway). The most used features of the acute care patient portal were the laboratory test results, care team information, and medication list. Most users accessed the portal between 1 to 4 days during their hospitalization, and the average number of days used (logged in at least once per day) was 1.8 days. On average, users accessed the portal 42.69% of the hospital days during which it was available. There was significant association with patient activation on the neurology service (P<.001) and medicine service (P=.01), after the introduction of HIT tools and the acute care patient portal, but not on the oncology service.

Conclusions

Portal users most often accessed the portal to view their clinical information, though portal usage was limited to only the first few days of enrollment. We found an association between the use of the portal and HIT tools with improved levels of patient activation. These tools may help facilitate patient engagement and improve outcomes when fully utilized by patients and care partners. Future study should leverage usage metrics to describe portal use and assess the impact of HIT tools on specific outcome measures in the hospital setting.

Identification of Pasteurella multocida virulence genes in a septicemic mouse model using signature-tagged mutagenesis

P. multocida is the causative agent of several economically significant veterinary diseases occurring in numerous species worldwide. Signature-tagged mutagenesis (STM) is a powerful genetic technique used to simultaneously screen multiple transposon mutants of a pathogen for their inability to survive in vivo. We have designed an STM system based on a mini-Tn10 transposon, chemiluminescent detection and semi-quantitative analysis and have identified transposon insertions into genes of Pasteurella multocida that attenuate virulence in a septicemic mouse model. A bank of 96 transposons containing strongly-hybridizing tags was used to create 19 pools of P. multocida transposon mutants containing approximately 70-90 mutants/pool. A total of 62 mutants were attenuated when checked individually, and 25 unique single transposon insertion mutations were identified from this group. The sequence of the disrupted ORF for each attenuated mutant was determined by either cloning or PCR-amplifying and sequencing the flanking regions. The attenuated mutants contained transposon insertions in genes encoding biosynthetic enzymes, virulence factors, regulatory components and unknown functions. This study should contribute to an understanding of the pathogenic mechanisms by which P. multocida and other pathogens in the Pasteurellaceae family cause disease and identify novel live vaccine candidates and new potential antibiotic targets.

Identification of Actinobacillus pleuropneumoniae virulence genes using signature-tagged mutagenesis in a swine infection model

Actinobacillus pleuropneumoniae is a significant respiratory pathogen of swine causing a severe and often fatal fibrinous hemorrhagic bronchopneumonia with significant economic losses resulting from chronic as well as acute infections. This study describes the application of a signature-tagged mutagenesis (STM) system to identify in vivo critical genes of A. pleuropneumoniae. Twenty pools representing over 800 A. pleuropneumoniae mutants were screened in a natural-host porcine infection model and presumptive attenuated mutants were selected. The identity of the disrupted gene in each mutant was determined using an inverse PCR approach to amplify DNA sequences adjacent to the transposon insertion, followed by sequencing of the PCR product and comparison to bacterial databases. In vitro and in vivo competitive indices were determined for each unique mutant, and a total of 20 unique, attenuating gene disruptions were identified including insertions into homologues of genes involved in biosynthesis, virulence determinants, regulation, translation and unknown functions. Three of the genes required for virulence of A. pleuropneumoniae in this study were also identified in a previous STM study of Pasteurella multocida. Seven of the STM-derived mutants were also evaluated for their potential as live vaccine strains and provided good protection against homologous challenge.

A genetically-defined riboflavin auxotroph of Actinobacillus pleuropneumoniae as a live attenuated vaccine

Actinobacillus pleuropneumoniae is a gram negative pleiomorphic rod that is the causative agent of a severe, highly infectious and often fatal pleuropneumonia in swine. We have previously reported the construction of genetically-defined stable riboflavin auxotrophs by replacement of a portion of the APP riboflavin biosynthetic operon (ribGBAH) with an antibiotic cassette encoding resistance to kanamycin, and have demonstrated that such riboflavin auxotrophs are avirulent. In this study, we evaluated riboflavin auxotrophs of A. pleuropneumoniae for their ability to stimulate protective immunity against pleuropneumonia. An initial challenge experiment demonstrated that intramuscular vaccination with a live attenuated serotype 1A rib mutant, in a vaccine formulation that included a limiting amount of exogenous riboflavin, provided better protection against challenge with virulent A. pleuropneumoniae than either intratracheal immunization or intramuscular immunization with live bacteria in the absence of exogenous riboflavin. Subsequent studies in which the vaccine inoculating dose, concentration of exogenous riboflavin, and serotype of the vaccine strain were varied demonstrated that immunization with live avirulent riboflavin auxotrophs could elicit significant protection against experimental challenge with both homologous and heterologous virulent serotypes of A. pleuropneumoniae.

Identification of in vivo induced genes in Actinobacillus pleuropneumoniae

We have developed an in vivo expression technology (IVET) system to identify Actinobacillus pleuropneumoniae gene promoters that are specifically induced in vivo during infection. This system is based upon an avirulent riboflavin-requiring A. pleuropneumoniae mutant and a promoter-trap vector (pTF86) that contains, in sequence, the T4 terminator, a unique Bam HI site, a promoterless copy of the V. harveyi luxAB genes, and a promoterless copy of the B. subtilis ribBAH genes in the E. coli - A. pleuropneumoniae shuttle vector pGZRS19. Sau 3A fragments of A. pleuropneumoniae genomic DNA were cloned into the Bam HI site in pTF86 and transformed into the A. pleuropneumoniae Rib- mutant. Pigs were infected with pools of 300-600 transformants by endobronchial inoculation and surviving bacteria were isolated from the pigs' lungs at 12-16 h post-infection. Infection strongly selected for transformants containing cloned promoters which drove expression of the vector ribBAH genes and allowed survival of the Rib- mutant in vivo. Strains that survived in vivo, but which minimally expressed luciferase activity in vitro, should contain cloned promoters that are specifically induced in vivo. Ten clones, designated iviA-J, were isolated which contain promoters that are induced in vivo during infection. These ivi clones were shown to be induced in the animal by luminescence of infected tissue and by direct assay of bacteria recovered from bronchoalveolar lavage. Four of these clones were putatively identified by amino acid sequence similarity as ilvI, the ilvDA operon, the secE-nusG operon, and the mrp gene. This is the first report of an IVET system for use in the family Pasteurellaceae, as well as the first report of an IVET system utilizing an infection model of pneumonia in the natural host.

A riboflavin auxotroph of Actinobacillus pleuropneumoniae is attenuated in swine

Actinobacillus pleuropneumoniae is the etiological agent of a highly contagious and often fatal pleuropneumonia in swine. A riboflavin-requiring mutant of A. pleuropneumoniae serotype 1, designated AP233, was constructed by deleting a portion of the riboflavin biosynthetic operon (ribGBAH) and replacing it with a gene cassette encoding kanamycin resistance. The genes affected included both the alpha- and beta-subunits of riboflavin synthase as well as a bifunctional enzyme containing GTP cyclohydrase and 3,4-dihydroxy-2-butanone-4-phosphate synthase activities. AP233 was unable to grow in the absence of exogenous riboflavin but otherwise was phenotypically identical to the parent wild-type strain. Experimental infection studies with pigs demonstrated that the riboflavin-requiring mutant was unable to cause disease, on the basis of mortality, lung pathology, and clinical signs, at dosages as high as 500 times the normal 50% lethal dose for the wild-type parent. This is the first demonstration of the attenuation of A. pleuropneumoniae by introduction of a defined mutation in a metabolic gene and the first demonstration that mutations in the genes required for riboflavin biosynthesis can lead to attenuation in a bacterial pathogen.

Characterization of Actinobacillus pleuropneumoniae riboflavin biosynthesis genes

In this paper, we report the identification, cloning, and complete nucleotide sequence of four genes from Actinobacillus pleuropneumoniae that are involved in riboflavin biosynthesis. The cloned genes can specify production of large amounts of riboflavin in Escherichia coli, can complement several defined genetic mutations in riboflavin biosynthesis in E. coli, and are homologous to riboflavin biosynthetic genes from E. coli, Haemophilus influenzae, and Bacillus subtilis. The genes have been designated A. pleuropneumoniae ribGBAH because of their similarity in both sequence and arrangement to the B. subtilis ribGBAH operon.