Center for Evidence-based Practice | University of Pennsylvania Health System

Penn Medicine's "Sepsis Sniffer" Generates Faster Sepsis Care and Suggests Reduced Mortality: Early identification and intervention lead to better results for hospital inpatients

October 9, 2014 — An automated early warning and response system for sepsis developed by Penn Medicine experts has resulted in a marked increase in sepsis identification and care, transfer to the ICU, and an indication of fewer deaths due to sepsis. A study assessing the tool is published online in the Journal of Hospital Medicine.

Sepsis is a potentially life-threatening complication of an infection; it can severely impair the body’s organs, causing them to fail. There are as many as three million cases of severe sepsis and 750,000 resulting deaths in the United States annually. Early detection and treatment, typically with antibiotics and intravenous fluids, is critical for survival.

The Penn prediction tool, dubbed the “sepsis sniffer,” uses laboratory and vital-sign data (such as body temperature, heart rate, and blood pressure) in the electronic health record of hospital inpatients to identify those at risk for sepsis. When certain data thresholds are detected, the system automatically sends an electronic communication to physicians, nurses, and other members of a rapid response team who quickly perform a bedside evaluation and take action to stabilize or transfer the patient to the intensive care unit if warranted.

The study developed the prediction tool using 4,575 patients admitted to the University of Pennsylvania Health System (UPHS) in October 2011. The study then validated the tool during a pre-implementation period from June to September 2012, when data on admitted patients was evaluated and alerts triggered in a database, but no notifications were sent to providers on the ground. Outcomes in that control period were then compared to a post-implementation period from June to September 2013. The total number of patients included in the pre and post periods was 31,093.

In both the pre- and post-implementation periods, four percent of patient visits triggered the alert. Analysis revealed 90 percent of those patients received bedside evaluations by the care team within 30 minutes of the alert being issued. In addition, the researchers found that the tool resulted in:

• A two to three-fold increase in orders for tests that could help identify the presence of sepsis

• A 1.5 to two-fold increase in the administration of antibiotics and intravenous fluids

• An increase of more than 50 percent in the proportion of patients quickly transferred to the ICU

• A 50 percent increase in documentation of sepsis in the patients’ electronic health record

The study found a lower death rate from sepsis and an increase in the number of patients successfully discharged home, although these findings did not reach statistical significance.

“Our study is the first we’re aware of that was implemented throughout a multihospital health system,” said lead author Craig A. Umscheid, MD, MSCE, director of Penn’s Center for Evidence-based Practice. “Previous studies that have examined the impact of sepsis prediction tools at other institutions have only taken place on a limited number of inpatient wards. The varied patient populations, clinical staffing, practice models, and practice cultures across our health system increases the generalizability of our findings to other health care settings.”

Umscheid also noted that the tool could help triage patients for suitability of ICU transfer. “By better identifying those with sepsis requiring advanced care, the tool can help screen out patients not needing the inevitably limited number of ICU beds.”

In addition to Umscheid, the other Penn co-authors are Joel Betesh, MD; Christine Vanzandbergen, PA, MPH; Asaf Hanish, MPH; Gordon Tait, BS; Mark E. Mikkelsen, MD, MSCE; Benjamin French, PhD; and Barry D. Fuchs, MD, MS.

Dr. Umscheid’s contribution to this project was supported in part by the National Institutes of Health, National Center for Advancing Translational Sciences, grant # UL1TR000003.

Penn Study: Electronic Alerts Significantly Reduce Catheter-Associated Urinary Tract Infections - Design of alerts crucial in achieving benefits for patients

August 22, 2014 — A Penn Medicine team has found that targeted automated alerts in electronic health records significantly reduce urinary tract infections in hospital patients with urinary catheters. In addition, when the design of the alert was simplified, the rate of improvement dramatically increased.

The alerts help physicians decide whether their patients need urinary catheters in the first place and then alert them to reassess the need for catheters that have not been removed within a recommended time period. The electronic alert, developed by medical researchers and technology experts at the Perelman School of Medicine at the University of Pennsylvania, is the subject of a study published in the September issue of Infection Control and Hospital Epidemiology.

Approximately 75 percent of urinary tract infections acquired in the hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. According to the Centers for Disease Control and Prevention, 15 to 25 percent of hospitalized patients receive urinary catheters during their hospital stay. As many as 70 percent of urinary tract infections in these patients may be preventable using infection control measures such as removing no longer needed catheters resulting in up to 380,000 fewer infections and 9,000 fewer deaths each year.

“Our study has two crucial, applicable findings,” said the Penn study’s lead author Charles A. Baillie, MD, an internal medicine specialist and fellow in the Center for Clinical Epidemiology and Biostatistics at Penn Medicine. “First, electronic alerts do result in fewer catheter-associated urinary tract infections. Second, the design of the alerts is very important. By making the alert quicker and easier to use, we saw a dramatic increase in the number of catheters removed in patients who no longer needed them. Fewer catheters means fewer infections, fewer days in the hospital, and even, fewer deaths. Not to mention the dollars saved by the health system in general.”

In the first phase of the study, two percent of urinary catheters were removed after an initial “off-the-shelf” electronic alert was triggered (the stock alert was part of the standard software package for the electronic health record). Hoping to improve on this result in a second phase of the study, Penn experts developed and used a simplified alert based on national guidelines for removing urinary catheters they had previously published with the CDC. Following introduction of the simplified alert, the proportion of catheter removals increased more than seven-fold to 15 percent.

The study also found that catheter associated urinary tract infections decreased from an initial rate of .84 per 1,000 patient days to .70 per 1,000 patient-days following implementation of the first alert and .50 per 1,000 patient days following implementation of the simplified alert. Among other improvements, the simplified alert required two mouse clicks to submit a remove-urinary-catheter order compared to seven mouse clicks required by the original alert.

The study was conducted among 222,475 inpatient admissions in the three hospitals of the University of Pennsylvania Health System between March 2009 and May 2012. In patients’ electronic health records, physicians were prompted to specify the reason (among ten options) for inserting a urinary catheter. On the basis of the reason selected, they were subsequently alerted to reassess the need for the catheter if it had not been removed within the recommended time period based on the reason chosen.

Women’s health units had the highest proportion of alerts that led to a remove-urinary-catheter order and critical care units saw the lowest proportion of alerts leading to a remove order.

“As more hospitals adopt electronic health records, studies such as ours can help point the way toward improved patient care,” said senior author Craig Umscheid, MD, MSCE, assistant professor of Medicine and Epidemiology and director of Penn’s Center for Evidence-based Practice. “Thoughtful development and deployment of technology solutions really can make a difference. In this study, we learned that no two alerts are alike, and that changes to an alert’s usability can dramatically increase its impact.”

Several studies have already shown that reminder systems to limit the use and duration of urinary catheters can lower catheter infection rates. However, the majority of these have used non-computerized reminders, such as written reminders or stickers. The current Penn study is one of the largest to examine the impact of electronically generated alerts. In addition to the size of the study, a second strength is its multi-year duration. Most prior studies relied on a brief study period, and several studies observed an increase in catheter use when the relatively brief intervention had ended.

In addition to Baillie and Umscheid, other Penn Medicine co-authors are Mika Epps, MSN, RN; Asaf Hanish, MPH; Neil O. Fishman, MD; and Benjamin French, PhD.

Link Between Ritual Circumcision Procedure and Herpes Infection in Infants Examined by Penn Medicine Analysis

July 24, 2014 — A rare procedure occasionally performed during Jewish circumcisions that involves direct oral suction is a likely source of herpes simplex virus type 1 (HSV-1) transmissions documented in infants between 1988 and 2012, a literature review conducted by Penn Medicine researchers and published online in the Journal of the Pediatric Infectious Diseases Society found. The reviewers, from Penn’s Center for Evidence-based Practice, identified 30 reported cases in New York, Canada and Israel.

The practice—known as metzitzah b’peh—and its link to HSV-1 infections have sparked international debate in recent years, yet no systematic review of the literature has been published in a peer-reviewed journal examining the association and potential risk. During metzitzah b’peh, the mohel, a Jewish person trained to perform circumcisions, orally extracts a small amount of blood from the circumcision wound and discards it.

Lead author Brian F. Leas, MS, MA, a research analyst in the Center for Evidence-based Practice at the University of Pennsylvania Health System, identified six relevant studies for the systematic review. All six studies were descriptive case reports or case series that documented neonatal HSV-1 infections after circumcision with direct oral suction.

“There is sufficient clinical evidence to suggest the practice is a source of infection and therefore a risk exists—though the extent or magnitude of that risk is not well defined and warrants further investigation,” said Leas. All of the studies, the authors report, presented clinical findings consistent with the transmission of infection from mohel to infant, including the location of HSV lesions, timing of symptoms, and HSV type. Two infants died, whereas others experienced mild to severe symptoms of the virus.

More than half of American adults are infected with HSV-1, which frequently presents itself as oral lesions, or cold sores, though many people never or rarely develop symptoms. Newborns infected with HSV-1, on the other hand, can become very sick quickly with high fever and seizures, and it can even cause death. Herpes simplex virus type 2 is a sexually-transmitted disease and is characterized by genital lesions, and is less common, affecting about 16 percent of adults.

The practice of metzitzah b’peh has been used in some ultra-Orthodox Jewish circles; however, the researchers note it is unclear how many metzitzah b’pehs take place in the United States per year.

The New York City Department of Health and Mental Hygiene instituted regulations in the fall of 2012, after a number of babies contracted herpes following the practice. Mohels in New York City are required to obtain written consent from parents before performing metzitzah b’peh. New York City has a relatively higher population of those who identify as ultra-Orthodox compared to the rest of the country.

In a 2012 report, an American Academy of Pediatrics task force concluded that circumcision is safe and provides overall health benefits, including reducing the risk of HIV, but advised against direct oral suction due to risk of infection.
“Neonatal herpes infection can cause severe morbidity and potentially death, so mitigating potential risks for infection is critical,” the authors write. “More research using cohort or case-control designs to fully capture all the relevant data is needed to clarify the real-world risk of HSV-1 infection associated with metzitzah b’peh.”Craig A. Umscheid, MD, MSCE, an assistant professor of Medicine and Epidemiology at the Perelman School of Medicine and Director of Penn Medicine’s Center for Evidence-based Practice, was the senior author on the study.

Major Gaps in Hepatitis C Care Identified As New Drugs and Screening Efforts Emerge, Penn Study Finds.
Less than 10 percent of People Infected with Hepatitis C are Cured

July 2, 2014 — A new meta-analysis published online in PLOS ONE by infectious disease and epidemiology specialists from the Perelman School of Medicine at the University of Pennsylvania highlights significant gaps in hepatitis C care that will prove useful as the U.S. health care system continues to see an influx of patients with the disease because of improved screening efforts and new, promising drugs.

In the largest study of its kind, the team examined data culled from 10 studies between 2003 and 2013 and found that less than 10 percent of people infected with hepatitis C in the United States — 330,000 of nearly 3.5 million people — were cured (achieved viral suppression) with antiviral hepatitis C treatment. The researchers also found that only 50 percent of people were diagnosed and aware of their infection; 43 percent of those with the disease had access to outpatient care; and only 16 percent were prescribed treatment.

“This study puts forth a good baseline of hepatitis C care in the United States over the last 10 years—which will be useful in monitoring the success and impact of new screening efforts and advances in antiviral therapy,” said the study’s first author,Baligh Yehia, MD, MPP, MSHP, an assistant professor of Medicine in Penn’s division of Infectious Diseases. “There are many people who don’t know that they have the infection, don’t have access to hepatitis C care and medications, and who haven’t been treated. With this data, we can see these gaps more clearly. This information will be useful for ensuring better access to hepatitis c care and treatment in the coming years.”
In June, the Centers for Medicare and Medicaid Services began reimbursing for hepatitis C virus screenings for two target populations, including baby boomers (those born between 1945 through 1965) and those at high risk for the infection. Six months prior, the U.S. Food & Drug Administration (FDA) approved sofosbuvir, an oral medication shown to cure most cases of hepatitis C infection, with fewer side effects than the current treatment options. Other drugs — which have shown success in clinical trials, some conducted at Penn Medicine—are expected to gain FDA approval within the year.

“The new regimens will be game changers in the treatment of chronic hepatitis C,” said senior author Vincent Lo Re III, MD, MSCE, assistant professor of Medicine and Epidemiology in the division of Infectious Diseases and department of Biostatistics and Epidemiology at Penn. “Given the high prevalence of this infection, particularly in baby boomers who didn’t know they were infected, having new, highly-effective treatment options to eradicate the virus will be a tremendous benefit to patients that will ultimately help us to reduce liver-related complications and re-infection rates.”

Such advances are expected to increase the number of patients treated for the disease. In the 1990s, HIV treatment turned a monumental corner with the advent of antiretroviral therapy. “It’s a very similar situation that we can learn from,” said Yehia. “With those advances, came challenges with access to and engagement in care. As hepatitis C therapy continues to advance, a focus on improving diagnosis, linkage to care, and insurance coverage will be more critical.”

The team screened close to 10,000 articles before identifying 10 studies that address one or more steps in the cascade of care, ranging from diagnosis to viral suppression. Some of the data came from the National Health and Nutrition Examination Survey and the Chronic Hepatitis B and C Cohort study. The researchers addressed seven key steps along this cascade and estimated the following based off the data analyzed:

“The advent of new antiviral agents for hepatitis C will shorten treatment duration, likely increasing the number of people offered treatment, and improving cure rates, which are the final two steps of the hepatitis C treatment cascade,” said Yehia. “However, educating providers and the general public about prevention, care, and treatment, ensuring access to providers skilled in the treatment of hepatitis C, and addressing the high cost of these agents will be critical to maximizing the benefits of these new therapies.”
Co-authors of the study, which was funded by the National Institutes of Health, include Craig A. Umscheid, MD, MSCE, and Asher J. Schranz, MD.

Penn Experts Urge Focus on Reducing Preventable Hospital Readmissions, Estimated to Constitute Just 25 Percent of All Readmissions.
Current efforts may hinder quality improvement and unfairly penalize hospitals

June 25, 2014 — Experts from the Perelman School of Medicine at the University of Pennsylvania and Vanderbilt University suggest that the reporting of hospital readmission rates should be based exclusively on preventable or potentially preventable readmissions, in a review published online in the Journal of Hospital Medicine. Currently the Centers for Medicare and Medicaid Services (CMS) does not take into account whether a readmission is preventable when assessing hospitals’ performance on this quality metric.

Under the Affordable Care Act, hospitals must report readmission rates for heart attack, heart failure, and pneumonia to CMS. CMS then imposes financial penalties on institutions having an excessive number of readmissions that take place within 30 days following patient discharge. Additional medical conditions will be added in 2015. Many patients with these conditions suffer from additional illnesses that are complex and come with many co-morbid conditions.
“Reducing hospital readmissions is clearly important on many levels,” says lead author Julia G. Lavenberg, PhD, RN, a research analyst at Penn’s Center for Evidence-based Practice. “Patients prefer to remain at home, payers save money, and hospitals avoid financial penalties for having high readmission rates. But while current policy assumes that a significant proportion of readmissions are preventable, research tells us that this is simply not so. Moreover, there is no consensus in the medical and policy communities on how to define preventable readmissions, which is essential for taking action to reduce them.”

Other payers, such as private insurers, are likely to follow the federal lead and withhold funding for high readmission rates. As a result, hospitals and health systems nationwide are devoting significant time, effort, and money to reducing readmissions. Steps include increasing patient education before discharge, introducing or expanding home health visits, and working more closely with nursing homes and rehabilitation centers.

“Current research tells us that only about 25 percent of hospital readmissions are preventable,” says senior author Sunil Kripalani, MD, MSc, chief of the Section of Hospital Medicine at Vanderbilt University. “We urge a focus on preventing these readmissions, so that hospitals can enhance efforts in areas where it will have the greatest effect as well as ensure fair and equitable reporting of hospital performance.”

Until a validated measure of preventability is developed, the authors recommend several steps. First, the readmission time horizon should be reduced from the current 30 days to seven or 15 days, as research suggests that early readmissions – those within seven to 15 days of discharge -- are more likely preventable than those occurring later. Second, policymakers should take the socioeconomic status of patients into account by only comparing hospitals serving similar patient communities when determining penalties for excess readmission rates. Finally, adjusting for other community factors such as practice patterns and access to care is necessary to more accurately reflect factors under a hospital’s control.

“We’re encouraging a major shift in perspective,” adds co-author Craig A Umscheid, MD, MSCE, a hospitalist and Director of the Center for Evidence-based Practice at Penn. “We want policymakers to acknowledge that hospitals should not be penalized for factors beyond their control which may play an important role in readmissions, such as inadequate community health resources or severity of the patient’s illness.”

Such a shift would require agreement among healthcare researchers and policymakers on how to identify and measure preventable or potentially preventable readmissions. While there are existing methods for doing so, there is no consensus on which is best. Furthermore, some of these methods are proprietary and thus unavailable for evaluation by others. These methods use such techniques as identifying readmission for conditions closely related to the original diagnosis or complications arising from the original admission.

To rectify this gap, the authors urge healthcare researchers and policymakers to come to agreement on a transparent, universal method for defining preventable or potentially preventable readmissions. This could include algorithms -- based on insurance claims data -- that recognize patterned relationships between original and readmission diagnoses for a variety of medical conditions. Then, clinicians at individual hospitals could use these standards to evaluate whether individual readmissions were potentially preventable or not. In time, researchers could codify these individual decisions into best-practice standards to serve as guides for subsequent assessments.
In addition to Lavenberg and Umscheid, Penn co-authors include Brian Leas; Kendal Williams, MD; and David R. Goldmann, MD.

Dr. Umscheid was supported in part by the National Center for Research Resources and the National Center for Advancing Translational Sciences (UL1TR000003). Dr. Kripalani receives funding from the National Heart, Lung and Blood Institute (R01HL109388), and from CMS (1C1CMS331006-01 and 1C1CMS330979-01).

Penn Study Shows Automated Prediction Alert Helps Identify Patients at Risk for 30-Day Readmission

11/27/2013 An automated prediction tool which identifies newly admitted patients who are at risk for readmission within 30 days of discharge has been successfully incorporated into the electronic health record of the University of Pennsylvania Health System. The tool, developed by researchers at the Perelman School of Medicine, is the subject of a study published in the December issue of the Journal of Hospital Medicine.

The all-Penn team found that having been admitted to the hospital two or more times in the 12 months prior to admission is the best way to predict which patients are at risk for being readmitted in the 30 days after discharge. As a result of this finding, the automated tool is now able to identify patients as being “high risk” for readmission and creates a “flag” in their electronic health record. Upon admission of a high-risk patient, the flag appears next to the patient’s name in a column titled “readmission risk.” The flag can be double-clicked to display detailed information relevant to discharge planning including inpatient and emergency department visits over the previous 12 months, as well as information about the care teams, lengths of stay, and problem(s) associated with those prior admissions.

“The results we’ve seen with this tool show that we can predict, with a good deal of accuracy, patients who are at risk of being readmitted within 30 days of discharge,” said lead author Charles A. Baillie, MD, an internal medicine specialist and fellow in the Center for Clinical Epidemiology and Biostatistics at Penn Medicine. “With this knowledge, care teams have the ability to target these patients, making sure they receive the most intensive interventions necessary to prevent their readmission.”

Interventions proven to help reduce 30-day readmissions include enhanced patient education and medication reconciliation on the day of discharge, increased home services to provide a safe landing, follow up appointments soon after discharge, and follow-up phone calls to ensure an extra level of protection. In the process of medication reconciliation, pharmacists compare a patient's current hospital medication orders to all of the medications that the patient was taking at home prior to their hospital admission. This is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

In support of the study, the Penn Medicine Center for Evidence-based Practice identified in the published literature a number of variables associated with readmission to the hospital, including: prior admissions, visits to the emergency department, previous 30-day readmissions, and the presence of multiple medical disorders.

Using two years of retrospective data, the team examined these variables using their own local data and found that a single variable – prior admission to the hospital two or more times within a span of 12 months – was the best predictor of being readmitted in the future. This marker was integrated into the electronic health record and was studied prospectively for the next year. During that time, patients who triggered the readmission alert were subsequently readmitted 31 percent of the time. When an alert was not triggered, patients were readmitted only 11 percent of the time.
“By automating the process of readmission risk prediction, we were able to provide risk assessment quickly and efficiently in real time, enabling all members of the inpatient team to carry out a coordinated approach to discharge planning, with special attention paid to those identified as being at the highest risk for readmission,” said Craig A Umscheid, MD, MSCE, assistant professor of Medicine and Epidemiology, director of the Penn Medicine Center for Evidence-based Practice, and senior author on the study.

The risk assessment tool is part of a series of steps taken by Penn Medicine to reduce readmissions.

“Readmission rates should improve over time as the risk flag is used more routinely and the interventions necessary to reduce readmission rates for those identified as high risk are implemented,” said Baillie.

In addition to Baillie and Umscheid, other Penn Medicine co-authors include Christine VanZandbergen, Gordon Tait, Asaf Hanish, Brian Leas, Benjamin French, C. William Hanson, and Maryam Behta.
http://www.uphs.upenn.edu/news/News_Releases/2013/11/baillie/