INTRODUCTION:Learning health systems (LHSs) are usually created and maintained by single institutions or healthcare systems. The Indiana Learning Health System Initiative (ILHSI) is a new multi-institutional, collaborative regional LHS initiative led by the Regenstrief Institute (RI) and developed in partnership with five additional organizations: two Indiana-based health systems, two schools at Indiana University, and our state-wide health information exchange. We report our experiences and lessons learned during the initial 2-year phase of developing and implementing the ILHSI.METHODS:The initial goals of the ILHSI were to instantiate the concept, establish partnerships, and perform LHS pilot projects to inform expansion. We established shared governance and technical capabilities, conducted a literature review-based and regional environmental scan, and convened key stakeholders to iteratively identify focus areas, and select and implement six initial joint projects.RESULTS:The ILHSI successfully collaborated with its partner organizations to establish a foundational governance structure, set goals and strategies, and prioritize projects and training activities. We developed and deployed strategies to effectively use health system and regional HIE infrastructure and minimize information silos, a frequent challenge for multi-organizational LHSs. Successful projects were diverse and included deploying a Fast Healthcare Interoperability Standards (FHIR)-based tool across emergency departments state-wide, analyzing free-text elements of cross-hospital surveys, and developing models to provide clinical decision support based on clinical and social determinants of health. We also experienced organizational challenges, including changes in key leadership personnel and varying levels of engagement with health system partners, which impacted initial ILHSI efforts and structures. Reflecting on these early experiences, we identified lessons learned and next steps.CONCLUSIONS:Multi-organizational LHSs can be challenging to develop but present the opportunity to leverage learning across multiple organizations and systems to benefit the general population. Attention to governance decisions, shared goal setting and monitoring, and careful selection of projects are important for early success.

In 2006, the U.S. Centers for Disease Control and Prevention released revised recommendations for routinization of HIV testing in healthcare settings. Health professionals have been challenged to incorporate these guidelines. In March 2013, a routine HIV testing initiative was launched at a large urban academic medical center in a high prevalence region. The goal was to routinize HIV testing by achieving a 75% offer and 75% acceptance rate and promoting linkage to care in the inpatient setting. A systematic six-step organizational change process included stakeholder buy-in, identification of an interdisciplinary leadership team, infrastructure development, staff education, implementation, and continuous quality improvement. Success was measured by monitoring the percentage of offered and accepted HIV tests from March to December 2013. The targeted offer rate was exceeded consistently once nurses became part of the consent process (September 2013). Fifteen persons were newly diagnosed with HIV. Seventy-eight persons were identified as previously diagnosed with HIV, but not engaged in care. Through this process, patients who may have remained undiagnosed or out-of-care were identified and linked to care. The authors propose that this process can be replicated in other settings. Increasing identification and treatment will improve the individual patient's health and reduce community disease burden.

Background Surgical peer review might be characterized by assessment heterogeneity. Methods We performed a prospective, anonymous, peer review of surgeon and system performance during a morbidity and mortality conference. Results Twenty-two cases were reviewed by a mean of 48.9 respondents each, including attendings, fellows, and residents. A mean of 50% (standard deviation, 23%) of respondents identified some quality issue in each case, reflecting high heterogeneity. The mean percentage in identifying a system issue was 27%, and in identifying a physician issue was 37%. When identifying a physician issue, physician care was judged as appropriate by 72%, as controversial by 26%, or as inappropriate by 2%. Residents were more likely than attendings to identify system issues (odds ratio, 2.23) and physician issues (odds ratio, 3.58), but attendings were more likely to rate care controversial or inappropriate (odds ratio, 2.53). Conclusions Surgical peer reviews, even after group discussion, display substantial heterogeneity. Review methods should account for this heterogeneity.

Background Subtle decreases in platelet count may impede timely recognition of heparin-induced thrombocytopenia (HIT), placing the patient at increased risk of thrombotic events. Objective A clinical decision support system (CDSS) was developed to alert physicians using computerized provider order entry when a patient with an active order for heparin experienced platelet count decreases consistent with HIT. Methods Comparisons for timeliness of HIT identification and treatment were evaluated for the year preceding and year following implementation of the CDSS in patients with laboratory confirmation of HIT. Results During the intervention time period, the CDSS alert occurred 41,922 times identifying 2,036 patients who had 2,338 inpatient admissions. The CDSS had no significant impact on time from fall in platelet count to HIT laboratory testing (control 2.3 days vs intervention 3.0 days P = 0.30) and therapy (control 19.3 days vs intervention 15.0 days P = 0.45), and appeared to delay discontinuation of heparin products (control 1.3 days vs. intervention 2.9 days P = 0.04). However, discontinuation of heparin following shorter exposure duration and after smaller decrease in platelet count occurred during the intervention period. The HIT CDSS sensitivity and specificity were each 87% with a negative predictive value of 99.9% and positive predictive value of 2.3%. Conclusions Implementation of a CDSS did not appear to improve the ability to detect and respond to potential HIT, but resulted in increased laboratory testing and changes in clinician reactions to decreasing platelet counts that deserve further study.

Bender, Leila MD; Klingensmith, Mary E. MD, FACS; Freeman, Bradley D. MD, FACS; Dunagan, Clayton W. MD, MS; Gottlieb, Jonathan MD; Chapman, William C. MD, FACS; Hall, Bruce L. MD, PhD, MBA Author Information

OBJECTIVE To determine the incidence and manifestations of hypoglycemia in hospitalized patients receiving antihyperglycemic therapy. RESEARCH DESIGN AND METHODS The study was a 3-month prospective review of consecutive medical records of all adult, nonpregnant hospitalized patients at a 675-bed university hospital who experienced at least 1 blood glucose (BG) <or= 60 mg/dL within 48 hours of receiving an antihyperglycemic agent. MEASUREMENTS AND RESULTS Of 2174 patients receiving antihyperglycemic agents, 206 (9.5%) experienced 484 hypoglycemic episodes. Of these episodes, 29% occurred in patients with type 1 diabetes, 23% in the ICU, and 72% in patients receiving only insulin for hyperglycemia. More than 1 episode was experienced by 44% of the 206 patients. Furthermore, 4% (20 of 484) of the hypoglycemic episodes were associated with a hypoglycemia-related adverse event, defined as symptoms, signs, or injury. The mean BG of these episodes was 43.0 mg/dL, significantly lower than the mean BG of 50.9 mg/dL for the 464 episodes without adverse events (P = .01). One-third of the adverse events occurred with a BG between 50 and 60 mg/dL; half the adverse events, 10 episodes or 2% of all hypoglycemic episodes, were serious, involving seizures or an unresponsive patient. A decrease in enteral intake accounted for 40% of the episodes; none was attributed to medication error. Less than half the hypoglycemic patients had documented euglycemia within 2 hours. Sulfonylurea agents were associated with higher rates of hypoglycemia than were other oral agents. CONCLUSIONS Hypoglycemia in hospitalized patients taking antihyperglycemic agents is common; 1 in 25 episodes is associated with an adverse event. Opportunities exist to improve care, particularly around discontinuation of feeding.

Background: An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed. Methods: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures. Results: Of all small-bore nasogastric feeding-tube placements, 1.3%-2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. Conclusions: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.

An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed.This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures.Of all small-bore nasogastric feeding-tube placements, 1.3%-2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project.Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.

Pulmonary involvement with multiple myeloma occurs infrequently and may be difficult to distinguish from more common primary lung tumours, metastatic disease, or other pleural and parenchymal abnormalities. A patient who developed acute respiratory distress syndrome (ARDS) was subsequently found to have multiple myeloma with involvement of lung parenchyma by neoplastic plasma cells. Only one other report of ARDS in association with multiple myeloma was found, and there are no previous reports where the appearance of ARDS antedated a diagnosis of multiple myeloma. In patients with ARDS, parenchymal involvement from multiple myeloma should be included in the differential diagnosis.

PURPOSE: Evaluate the impact of a computerized order set on the adherence to core measures in patients with Community Acquired Pneumonia (CAP).

Journal Article Pharmacist interventions after implementation of computerized prescriber order entry Get access Craig Senholzi, B.S.Pharm., M.B.A., Craig Senholzi, B.S.Pharm., M.B.A. Medication Safety Coordinator, Department of Pharmacy Thomas Jefferson University Hospital, Philadelphia, PA Address correspondence to Mr. Senholzi at the Department of Pharmacy, Thomas Jefferson University Hospital, 111 South 11th Street, Suite 2260 Gibbon, Philadelphia, PA 19107 craig.senholzi@mail.tyu.edu Search for other works by this author on: Oxford Academic Google Scholar Jonathan Gottlieb, M.D. Jonathan Gottlieb, M.D. Senior Vice President for Clinical Affairs and Chief Medical Officer Thomas Jefferson University Hospital, Philadelphia, PA Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 60, Issue 18, 15 September 2003, Pages 1880–1882, https://doi.org/10.1093/ajhp/60.18.1880 Published: 15 September 2003

Objective; To determine whether the administration of lisofylline (1-[5R-hydroxyhexyl]-3,7-dimethylxanthine) would decrease mortality in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS).Design: A prospective, randomized, double-blind, placebo-controlled, multicenter study.Setting. Intensive care units at 21 hospitals at the ten centers constituting the ARDS Clinical Trials Network.Patients. A total of 235 patients who met eligibility criteria were enrolled in the study (116 into the lisofylline group, 119 into the placebo group).Interventions., Patients were randomized to receive either lisofylline or placebo. The dose of lisofylline was 3 mg/kg with a maximum dose of 300 mg intravenously every 6 hrs. The intravenous solution of study drug was administered over 10 mins every 6 hrs. Dosing was continued for 20 days or until the patient achieved 48 hrs of unassisted breathing.Measurements and Main Results. The trial was stopped by the Data Safety Monitoring Board for futility at the first scheduled interim analysis. The patient groups had similar characteristics at enrollment. No significant safety concerns were associated with lisofylline therapy. There was no significant difference between groups in the number of patients who had died at 28 days (31.9% lisofylline vs. 24.7% placebo, p = .215). There was no significant difference between the lisofylline and placebo groups in terms of resolution of organ failures, ventilator-free days, infection-related deaths, or development of serious infection during the 28-day study period. The median number of organ failure-free days for the five nonpulmonary organ failures examined (cardiovascular, central nervous system, coagulation, hepatic, and renal) was not different between the lisofylline and placebo groups. Although lisofylline has been reported to decrease circulating free fatty acid levels, we did not find any such treatment effect compared with placebo.Conclusions. In this study, there was no evidence that lisofylline had beneficial effects in the treatment of established ALI/ARDS.

Context The decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships.Objective To demonstrate a system that documents medical students' clinical experiences across clerkships.Design and Settings Evaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000.Participants A total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine.Main Outcome Measures Number of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records.Results Students completed 86011 patient encounter cards: 48367 cards by 582 students in family medicine, 22604 cards by 469 students in pediatrics, and 15040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings.Conclusions An instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education.

Context Three clinical studies have suggested that ketoconazole, a synthetic imidazole with anti-inflammatory activity, may prevent the development of acute respiratory distress syndrome (ARDS) in critically ill patients. However, the use of ketoconazole as treatment for acute lung injury (ALI) and ARDS has not been previously studied.Objective To test the efficacy of ketoconazole in reducing mortality and morbidity in patients with ALI or ARDS.Design Randomized, double-blind, placebo-controlled trial conducted from March 1996 to January 1997.Setting Twenty-four hospitals associated with 10 network centers in the United States, constituting the ARDS Network.Patients A total of 234 patients with ALI or ARDS.Intervention Patients were randomly assigned to receive ketoconazole, 400 mg/d (n=117),or placebo (n=117), initiated within 36 hours of fulfilling study entry criteria and given enterally for up to 21 days.Main Outcome Measures Primary outcome measures were the proportion of patients alive with unassisted breathing at hospital discharge and the number of days of unassisted breathing (ventilator-free days) during 28 days of follow-up. Secondary outcome measures included the proportion of patients achieving unassisted breathing for 48 hours or more, the number of organ failure-free days, and changes in plasma interleukin 6 (IL-6) and urinary thromboxane A(2) metabolites (thromboxane B-2 [TXB2] and 11-dehydro-TXB2).Results In-hospital mortality (SE) was 34.1 % (4.3 %) for the placebo group and 35.2 % (4.3 %) for the ketoconazole group (P=.85). The median number of ventilator-free days within 28 days of randomization was 9 in the placebo group and 10 in the ketoconazole group (P=.89). There were no statistically significant differences in the n umber of organ failure-free days, pulmonary physiology, or adverse events between treatment groups. The median serum ketoconazole level was 1.25 mu g/mL and serum levels greater than 0.5 mu g/mL were detected in 96% of patients assayed. Plasma IL-6, urinary TXB2, and 11-dehydro-TXB2 levels were unaffected by ketoconazole.Conclusions In these patients with ALI or ARDS, ketoconazole was safe and bioavailable but did not reduce mortality or duration of mechanical ventilation or improve lung function. These data do not support the use of ketoconazole,for the early treatment of ALI or ARDS.

Perceptions of medical school seniors about changes occurring in the health care environment were investigated A survey was completed by 196 Jefferson Medical College seniors in the class of 1997. Of the respondents, 79% believed that cost reduction rather than quality of care is the primary consideration behind recent changes, 78% felt that managed care organizations hamper physicians' abilities to render optimal care, 83% maintained that the control of health care by insurance companies would lead to lower quality of care, 69% agreed that patients should have the freedom to seek a specialist's care without being referred by a primary care physician, 82% recommended that mentally ill patients should be referred to a mental health professional, and 82% believed that learning to work in a managed care environment should be an essential component of medical education. Assessment of student perceptions can assist in the development and implementation of appropriate curricular changes.