Brad Doebbeling, Abel Kho, Heather Hagg, Jamie Workman, Mindy Flanagan, Kim McCoy, Shawn Hoke, Paul Dexter

IU Center for Health Services & Outcomes Research, Regenstrief InstituteVA Center of Excellence in Implementing Evidence-based PracticeIU School of Medicine, Indiana University-Purdue University-Indianapolis (IUPUI) & Northwestern UniversitySupported by a contract from AHRQ through ACTION.

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.

Consistent Use of Known Practices Work Target Modes of MRSA Transmission

Person-person via hands of health care providers

Personal equipment (e.g., stethoscopes, PDAs) and clothing

Environmental contamination▪ Healthcare environment▪ Home/Community environment

RN awareness of MRB status increased from 24% at baseline to 59% at 1 year. -93% at 1 year after notifying nurses.

Implementation of isolation precautions increased from 15% at baseline to 51% after 1st intervention and then to 90%.

RI electronic tool notifies staff of MRSA positive history at Wishard, based on micro data from all Indy hospitals (except VA).

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 contact

isolation. Cac et al Arch Intern Med. 2007;167(19):2086-0Kho et al J Am Med Inform Assoc 2008; 15:212-216

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

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

Technique to engage front line staff in owning & improving processes and sustaining change

Based on identification of practices of used by ‘positively deviant’ staff/departments

Critical for staff involvement/buy-in

What is Positive Deviance?What is Positive Deviance?

Integrated Lean/PD approachIntegrated Lean/PD approach

DevelopFuture State

Process

Process ControlStrategy

Baseline Current

Processes

Identify Operational

Barriers

Define the Problem

Discovery

Action

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)

• 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.

Preliminary pre and post intervention results for first three hospitals suggest average of 60% reduction on study units

~ 20% reduction hospital wideCurrently investigating optimal

biostatistical approach such as time series analysis to confirm

Infection control is a regional problem, requiring a coordinated effort

Created a citywide electronic notification system to prospectively track all known patients with MRSA

Currently track 17,000 patients with a history of MRSA infection or colonization across Indianapolis.

Since May 2007, delivered 2698 admission alerts on patients with a history of MRSA, 19 percent based on data from another institution.

20 infection control providers (ICPs) spanning 16 hospital

Kho, Lemmon, Dexter, Doebbeling AMIA 2008

Alerts

0

50

100

150

200

250

300

350

400

Alerts

An Operational Citywide Electronic Infection Control Network: Results from 1st Year

System redesign approach of training, consultation and coaching front-line staff seems to be strong, sustained approach

Importance of buy-in from highest institutional levels crucial

Enthusiasm builds from within because redesign teams own it!

Informatics tool helpful in identifying great cross-over of MRSA patients in hospitals

Our proposed data collection too intensive for most community hospitals

Need a better electronic data collection infrastructure relating to outcome data

Hospitals desire regular feedback on impact of interventions

Little time for paper writing (Hazard of short time lines for funding)

Engagement Process: The engagement process involves multiple social change processes centered on PD.

Outcome Data Feedback: Transmission and infection rates are shared with staff.

Process Data Feedback: Nursing unit staff track performance on infection control practices.

Learning Collaborative: Teams from hospitals connect with teams from other hospitals employing the MRSA Intervention Bundle to foster learning and innovation.

More extensive activities to train interdisciplinary teams within each of the participating health systems (compared with first study).

• Acting as assessment, technical, and resource center for AHRQ and 5 other AHRQ ACTION Partners:• Denver Health and Parkland Health, Texas• HRET (Michigan Hospital Association Keystone

Center )• Iowa• American Institutes for Research (AIR)• Yale

17

Indy Investigators—IU Center for Health Services & Outcomes Research, Regenstrief Institute:

Jamie Workman-German; Mindy Flanagan; Amber Welsh; Shawn Hoke; Brad Doebbeling

Goal of overall initiative to identify factors associated with implementation of training that can assist hospitals in successfully reducing and sustaining the reduction of infections associated with the process of care.

Training tools aimed at VAP, BSI, and SSI

• Facilitate and coordinate consistent collection of information across the HAI Initiative,

• Provide technical assistance to the 34 hospitals,

• Analyze and synthesize the information from the common information collection instruments,

• Share lessons learned about the barriers, solutions and PD practices in implementing and sustaining infection safety.

• Interdisciplinary group of collaborating investigators affiliated with VA sites distributed across the US. •Improve the health of veterans through foundational and applied informatics research. • Advance the effective use of unstructured text and other types of clinical data in the electronic health record. •Indy Team--Merchant, French, Saleem, Burton, Friedlin, Flanagan, Allen, Doebbeling

Salt Lake City VA, Indy VAMC, West Haven VA, Boston VA, Portland VA, Philadelphia VA, Nashville VA, Tampa VA, Regenstrief Inst., NLM, NIH, Mayo Clinic, Carnegie Mellon U., Vanderbilt U., U. of Pittsburgh, Oregon HS U., U. of Utah.

Concept extraction from clinical notes Retrieve clinical concepts and their modifiers

▪ Diagnoses, negation, temporality, ambiguity, etc. Develop knowledge from concepts

Develop new or more knowledge about a patient▪ Timelines, symptomology, patient models

Apply knowledge Use new knowledge to enhance patient care

▪ PTSD▪ Predict suicidailty▪ Find undiagnosed patients

▪ MRSA▪ Automate warnings to ICP & wards▪ Determine treatment efficacy

De-identification of sensitive dataConcept ExtractionClinically-relevant inference and

modelingDocument quality assessment Evaluation and annotation methods

NLP Systems

Methods

Classification

Clustering

Association Analysis

Outlier Detection

Machine Learning

Integrateddatabases

Tokenization

Systems Architecture

Structured Data

New structured data

De-identification systems

Vocabularies

Semantic Networks

Terminologies

Ontologies

Annotatedcorpora

Raw VistA text

POS tagging

Parsing

WSDSemantic tagging

Lexicon Structure analy.

Pattern recog.

Chunking

Grammars

Lexical analysis

Syntactic analysis

Semantic analysis

Code mappingSemantic analyzer

Two major applied projects to demonstrate the value of its research activities. --high priority for veteran’s health.•Methicillin-resistant Staphylococcus aureus (MRSA) infection (Indianapolis VAMC); •Post-traumatic stress disorder (PTSD).

New Pilot projects

Develop, review and refine an ontology for clinically and epidemiologically relevant concepts to enable detection of MRSA

Index MRSA-related Concepts in Clinical Narrative.

Clinical Inference and Analysis of MRSA-Related Information Contained in the Medical Record

Develop and evaluate a prototype surveillance application that uses automatically processed VA electronic health record data

Evaluate algorithms for making multi-type predictions based on heterogeneous data, using MRSA as a clinical domain.

Funding AHRQ ACTION Network, Hospital Acquired Infections Collaborative

VA HSR&D and Consortium for Healthcare Informatics Research

Indianapolis CollaboratorsAHRQ and VA Collaborators