Rapid Prospective Evaluation (RapidEval) Unit

Investigator: 

Brian Hilliard, MD

• Assistant Professor of Medicine, Division of General Internal Medicine, University of Minnesota
• Co-chair, Quality Committee, Hospital Medicine Domain, M Health Fairview

The problem: 

Within M Health Fairview hospitals, patient flow is critical for exceptional patient experience, clinical safety and cost efficiencies. We have observed that the cardiac monitoring (or telemetry) bed capacity is a bottleneck for patient flow in our system. Wide variation still exists among sites, units and physicians on what is considered appropriate use for telemetry. This inappropriate use leads to suboptimal uses of our staff time, skill sets, equipment and facilities, and limits access to telemetry for patients who need it.

The intervention:

The intervention will use a multi-faceted approach that incorporates decision aids into the electronic health record. First, clearer indications for use of telemetry, with links to evidence based literature, will be provided within the cardiac monitoring order. Second, best practice alerts (BPAs) will be displayed at the end of the guideline-supported duration for use. 

Outcomes:

This intervention aims to improve quality and safety by removing patients who don’t need telemetry, thus improving capacity and access for patients who need it. It can also improve the total cost of care by reducing patients’ length of hospital stay, financially benefiting both the health system and the patients.

Status:

In Progress

Investigator:

Arjun Gupta, MD

• Assistant Professor of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota

The problem:

Every year, over 30,000 Minnesotans are diagnosed with cancer, and cancer is the leading cause of death in Minnesota. Older adults with cancer have vulnerabilities (e.g., issues with function, comorbidity, cognition, and nutrition) that place them at high risk of chemotherapy toxicity. Unfortunately, busy oncologists do not have the time, resources, or infrastructure in clinic to assess or address these vulnerabilities in a systematic manner. This leads to higher rates of chemotherapy toxicity in older adults with cancer. 

The intervention:

The intervention will involve an on-screen electronic alert which will pop-up during the first clinic visit of eligible patients with their oncologist. The alert will inform the oncologist that the patient is at a high-risk of chemotherapy toxicity due to their age and comorbidities, and link to a free, online tool which calculates the risk of chemotherapy for individual patients (https://www.mycarg.org/?page_id=2405). 

Outcomes:

Incorporating chemotherapy toxicity tools into the electronic health record can inform patient-oncologist decision-making about whether and what chemotherapy to pursue, and decrease toxicity, primarily unplanned hospitalization. The intervention aims to improve patient outcomes, decrease burden on the healthcare system, and result in cost savings.

Status:

In progress

Investigator:

Ben Webber, MD

• Assistant Professor of Medicine, Division of General Internal Medicine

The problem:

Sepsis remains the leading cause of in-hospital mortality at MHealth Fairview despite a push for more standardized care. Process measures aimed at improving care involve early identification of patients at risk for sepsis and subsequent evaluation and treatment. Despite these processes being in place for over 5 years at MHealth Fairview, provider compliance remains poor. It is well established in the literature that antibiotic timing is associated with inpatient mortality, length of stay, and complication rates following diagnosis. Developing strategies to improve efficiency in recognition of sepsis and delivery of disease altering treatment is a priority across the country and the target of a national public health campaign.

The intervention:

This study will involve micro-educational interventions delivered to physicians, advanced practice providers, residents, students, and nurses who can impact clinical outcomes through increased awareness, knowledge, and clinical information that the intervention targets, i.e. sepsis recognition, treatment, and outcomes. As the education pieces disseminate, the interventions themselves will change and adapt to better cater to the new clinical reality and scenario that the previous intervention helped create. In the process, creating a replicable framework for iterative education to impact future clinical outcomes or targets.

Status:

In progress

Investigator:

Sagar Deshpande, MD

• Surgical Resident, University of Minnesota Medical School

The problem:

It is no secret that post-surgical opiate counseling is often suboptimal. But even with ideal counseling, the deck can be stacked against patients. Patients must remember instructions weeks-to-months later, despite being in great pain or already on opiate medications at the time of counseling. At baseline, patients have poor and inaccurate memories for medical advice, especially with regard to treatment, and the very pain that necessitates opiate medication only exacerbates that issue. The confluence of these factors potentiates patients towards addiction. To overcome these barriers, a partnership is necessary between the care team and patient in a co-productive initiative to use and discontinue opiate medication usage. 

The intervention:

Behavioral economics offers a novel perspective to the problems of opiate overutilization and diversion rather than the existing medical approach. By harnessing the natural tendencies of populations, changes in behavior and decision-making can be induced. We are developing a “chatbot”- type artificial intelligence (AI) application (“OPY”) which counsels patients on appropriate opiate usage and delivers timely information to patients who are prescribed new opiate medications. Using insights from behavioral economics, we have designed and tested various “nudges,” or informational framing schemes, regarding information on opiate weaning and disposal. These nudges will instruct patients on how to optimize their pain control, maximize their ability to wean off their opiates, and dispose of their medications safely and legally.

Status:

In progress

Investigator: 

Shana Steinbeck, PharmD, BCPS

• Clinical Pharmacy Manager, Residency Program Director, M Health Fairview, Woodwinds Health Campus

The problem: 

The inpatient pharmacist assesses all patient admission medication histories, inpatient medications, and discharge medications for indication, effectiveness, safety, and convenience.

Currently, a medication therapy management (MTM) referral is placed for M Health Fairview patients with certain high-risk disease states and/or polypharmacy based on an Epic formula.

Research has shown the benefit of MTM pharmacist inclusion on care teams through alleviating chronic disease risk factors and monitoring patients for clinical care needs. 

Unfortunately, there are currently no pharmacist assessment questions nor an Epic formula that can identify patients with potential economic instability who would benefit from MTM care. The inclusion of social determinants of health, such as economic stability, can directly impact a patient's ability to afford their medications, and, therefore, maintain adherence and reduce disease progression.

The intervention:

This proposal aims to identify patients with potential economic instability and refer them to MTM services. The hypothesis is that the inclusion of patients who may not be able to afford their medications in the MTM referral process will ultimately reduce medication non-adherence, which will impact patient morbidity and health care utilization in the long-term.

Status:

In Progress

Investigator:

Christopher Streib, MD

• Associate Professor, Department of Neurology; Vascular Neurology Fellowship Director, University of Minnesota; Cerebrovascular Director, M Health Fairview

The problem:

Stroke is the fifth leading cause of death and number one cause of long-term disability in the United States. For patients presenting to the hospital with acute ischemic stroke, urgent diagnostic stroke evaluation and immediate initiation of targeted secondary stroke prevention is essential. 

However, due to a severe shortage of stroke neurologists, timely specialist stroke care is often unavailable. This is problematic because fragmented and inconsistent stroke care reinforces known racial and geographic healthcare disparities.

The intervention:

It is our intent to utilize telemedicine ("telestroke") to facilitate urgent stroke specialist care for all hospitalized M Health Fairview stroke patients regardless of geographic location.

We aim to test the impact of this care model on multiple relevant stroke care outcomes, including the percent of acute ischemic stroke patients who receive an urgent telemedicine stroke, recurrent stroke rate, and readmission rate among other outcomes.

Status:

In progress

Investigator:

Bronwyn Southwell, MD

• Assistant Professor, Department of Anesthesiology, University of Minnesota Medical School

The problem:

Surgical site infections (SSIs) are responsible for a large proportion of infections acquired at hospitals. The team that submitted this proposal developed a bundle of evidence-based strategies aimed at decreasing these infections, but found that adherence rates were below their target. This project seeks to to increase adherence to this set of interventions aimed at decreasing the amount of SSIs.

The intervention:

To improve adherence rates, this team proposed a dedicated surgical ‘time-out’.  Before making an incision, clinicians in the operating room will pause and go through the different parts of the bundle.

The providers will also document the pause in their patient’s electronic health record in order to track adherence to the initiative.

Status:

In progress

Investigator:

Zachary Kaltenborn, MD

• Assistant Professor of Medicine and Pediatrics, University of Minnesota Medical School

The problem:

Pre-exposure prophylaxis (PrEP) is effective at stopping adolescents and adults from contracting HIV when combined with emtricitabine-tenofovir DF or emtricitabine-tenofovir alfenamide. However, there is a large gap between patients eligible for PrEP and patients who actually receive it.

One major barrier to providing PrEP is that the guidelines for prescribing it are confusing, which makes it difficult for providers to determine if a patient should be prescribed it. The purpose of this project is to make PrEP easier to provide so that disparities between who qualifies for PrEP and who actually receives it are reduced.

The intervention:

The project seeks to address the barriers for prescribing PrEP by creating a smart set in Epic for prescribing PrEP. The team also proposed creating an alert that notifies healthcare providers when a patient’s electronic health record indicates they have a high risk of contracting HIV.

Finally, the team is also looking to create an After Visit Summary that includes information about PrEP and links to a social media campaign designed to raise awareness about PrEP.

Status:

In progress