Prabhu Shankar

Impact of a rapid respiratory panel test on patient outcomes.

CONTEXT Evolution of polymerase chain reaction testing for infectious pathogens has occurred concurrent with a focus on value-based medicine. OBJECTIVE To determine if implementation of the FilmArray rapid respiratory panel (BioFire Diagnostics, Salt Lake City, Utah) (hereafter RRP), with a shorter time to the test result and expanded panel, results in different outcomes for children admitted to the hospital with an acute respiratory tract illness. DESIGN Patient outcomes were compared before implementation of the RRP (November 1, 2011, to January 31, 2012) versus after implementation of the RRP (November 1, 2012, to January 31, 2013). The study included inpatients 3 months or older with an acute respiratory tract illness, most admitted through the emergency department. Testing before RRP implementation used batched polymerase chain reaction analysis for respiratory syncytial virus and influenza A and B, with additional testing for parainfluenza 1 through 3 in approximately 11% of patients and for human metapneumovirus in less than 1% of patients. The RRP tested for respiratory syncytial virus, influenza A and B, parainfluenza 1 through 4, human metapneumovirus, adenovirus, rhinovirus/enterovirus, and coronavirus NL62. RESULTS The pre-RRP group had 365 patients, and the post-RRP group had 771 patients. After RRP implementation, the mean time to the test result was shorter (383 minutes versus 1119 minutes, P < .001), and the percentage of patients with a result in the emergency department was greater (51.6% versus 13.4%, P < .001). There was no difference in whether antibiotics were prescribed, but the duration of antibiotic use was shorter after RRP implementation (P = .003) and was dependent on receiving test results within 4 hours. If the test result was positive, the inpatient length of stay (P = .03) and the time in isolation (P = .03) were decreased after RRP implementation compared with before RRP implementation. CONCLUSIONS The RRP decreases the duration of antibiotic use, the length of inpatient stay, and the time in isolation.

Risk factors for quantity not sufficient sweat collection in infants 3 months or younger.

OBJECTIVES The purpose is to identify demographic characteristics associated with a quantity not sufficient (QNS) sweat collection in infants 3 months or younger. METHODS History of premature birth, infant race and sex, gestational age at delivery, and weight of the infant were compared with QNS collection. RESULTS Of 221 sweat collections from 197 infants, 25 were QNS. Infant weight less than 3 kg and history of prematurity were associated with QNS collection (P < .001). Thirteen (30.2%) of 43 infants weighing less than 3 kg had QNS collections compared with 12 (7.9%) of 151 infants 3 kg or more. Twelve (46.2%) premature infants had QNS collections compared with 13 (7.6%) term infants. Lower birth gestational age and corrected gestational age were associated with QNS collections. Six (86%) of seven infants who weighed less than 3 kg, had a history of prematurity, and were more than 54 days old at testing had a QNS result. Sex and race did not correlate with QNS collections. CONCLUSIONS Weight less than 3 kg and history of prematurity are associated with an increased chance of QNS sweat collections.

Mucosal Healing in Clinical Practice: A Single-Center Pediatric IBD Experience

Background: Mucosal healing (MH) is associated with improved clinical outcomes in patients with Crohns disease (CD) and ulcerative colitis (UC). MH as a target for treatment has been suggested, although there is little pediatric data. The goal of this study was to evaluate MH in clinical practice in pediatric patients with inflammatory bowel disease in clinical remission. Methods: A retrospective review of electronic health record data was performed on all patients with CD or UC who underwent at least 2 colonoscopies from 2010 through 2016. Only patients in clinical remission undergoing a scope for MH were included in our study. The incidence of MH and histologic healing (HH) was analyzed, along with cumulative rates of MH in each group. MH was defined by both physician assessment of MH and an endoscopic score of zero for CD and UC. Results: A total of 76 patients with CD and 28 patients with UC underwent at least one MH scope while in clinical remission. Of the 76 patients with CD, 51 patients (67%) demonstrated MH by physician assessment, 34 patients (45%) demonstrated MH by a simple endoscopic score for CD of zero, and 35 patients (46%) demonstrated HH. Of the 28 patients with UC, 20 patients (71%) demonstrated MH by physician assessment, 10 patients (36%) demonstrated MH by a Mayo score of zero, and 10 patients (36%) demonstrated HH. Nineteen patients underwent a second MH scope and 11 (58%) demonstrated MH by physician assessment, 7 patients (37%) demonstrated MH by simple endoscopic score for CD or Mayo scores of zero, and 5 patients (26%) demonstrated HH. Of those patients with active disease, 21 of 25 patients with CD underwent escalation of therapy, whereas 8 of 8 patients with UC underwent escalation of therapy. Cumulative rates of MH when defined by physician assessment were 79% (60 of 76 patients) in CD and 79% (22 of 28 patients) in UC. Conclusions: MH is feasible in pediatric CD and UC, and rates of cumulative MH in pediatric patients are similar to previously published adult data. In children with inflammatory bowel disease in clinical remission, approximately one-third demonstrate active disease at endoscopy.

Advances in Sharing Multi-sourced Health Data on Decision Support Science 2016-2017

Summary Introduction:  Clinical decision support science is expanding to include integration from broader and more varied data sources, diverse platforms and delivery modalities, and is responding to emerging regulatory guidelines and increased interest from industry. Objective:  Evaluate key advances and challenges of accessing, sharing, and managing data from multiple sources for development and implementation of Clinical Decision Support (CDS) systems in 2016-2017. Methods:  Assessment of literature and scientific conference proceedings, current and pending policy development, and review of commercial applications nationally and internationally. Results:  CDS research is approaching multiple landmark points driven by commercialization interests, emerging regulatory policy, and increased public awareness. However, the availability of patient-related “Big Data” sources from genomics and mobile health, expanded privacy considerations, applications of service-based computational techniques and tools, the emergence of “app” ecosystems, and evolving patient-centric approaches reflect the distributed, complex, and uneven maturity of the CDS landscape. Nonetheless, the field of CDS is yet to mature. The lack of standards and CDS-specific policies from regulatory bodies that address the privacy and safety concerns of data and knowledge sharing to support CDS development may continue to slow down the broad CDS adoption within and across institutions. Conclusion:  Partnerships with Electronic Health Record and commercial CDS vendors, policy makers, standards development agencies, clinicians, and patients are needed to see CDS deployed in the evolving learning health system.

Remote monitoring and discrete data capture of joint pain and other parameters via the NokiaN900 device: Enhancing patient/physician interaction

The new generation cellular phones have multi-functional capabilities such as imaging, video, audio recording and messaging in addition to providing internet access. In this paper we present an innovative application in the field of remote health monitoring using N900 Nokia tablet, which will serve as a communicating device between the patient and healthcare providers like doctors and nurses. Patients with arthritis require regular objective monitoring of their affected joints by healthcare providers requiring that patients report their subjective pain levels to their physicians. The application has a patients module allowing the patient to select their pain level on a sliding scale from a graphical representation of various human joints and send this as an SMS to the doctor. The healthcare providers can review the pain level, save it to a database and make an informed decision about possible recommendations based on the data received via SMS. The doctors module allows the doctor to capture all the attributes of an affected joint discretely using the graphical representation of the joints and associated dialog boxes. The complete Graphical User Interface (GUI) development and data base design are discussed and test cases are presented. We plan to evaluate the application in a real healthcare environment for usability, its role in improving patient satisfaction and health outcomes.

Real time access to online immunization records and its impact on tetanus immunization coverage in the ED

The objective of this study was to evaluate the impact of online access to the state Immunization Information Systems (IIS) on the immunization practices of emergency department (ED) providers in a pediatric academic tertiary care center. Interoperability between Health Information Systems (HIS) such as Electronic Health Records (EHRs), Laboratory Information Systems (LIS), and health registries, maintained by various care providers (e.g., primary/specialty care, ED, inpatient hospital systems) and public health departments (e.g., IIS, formerly referred to as immunization registries) are required for full realization of healthcare reform, set forth by the Affordable Care Act [1], [2]. Pediatric immunization is mainly covered by the primary care providers, supplemented in certain circumstances by alternative settings such as the ED and hospitals. It is critical that updated immunization records of individual patients are available at the Point-Of-Care (POC), to help decide the need for an immunization, such as tetanus vaccination in trauma patients, and prevent over or under immunization. To provide up-to-date information about immunization administered to individual patients by all care providers, with a view to improve immunization coverage and reduce unnecessary and duplicate immunization, the Georgia Department of Public Health (DPH) created a population based IIS (Georgia Registry of Immunization Transactions and Services or GRITS) [3]. Childrens Healthcare of Atlanta worked with the DPH to establish an interface between their EHR system and GRITS so that the updated immunization records could be accessed online within the EHR at POC. This online access could also be viewed as a golden opportunity to improve the Center for Disease Control (CDC) recommended Tetanus, Diphtheria and Pertussis (Tdap) coverage for the 11 to 19 year-old children, known to be difficult population to reach out to, to improve Tdap coverage targets. We compared the immunization coverage practices, based on CDC recommendations, in patients 10 to 20 years of age, presenting with trauma where tetanus immunization was indicated, pre-post availability of GRITS via EHR. At implementation onset, there was a significant increase in vaccination rates (2.3%, p=0.01), but, the increase was not sustained and the pre-implementation downward trend continued (p=0.91). There were only 4 patients who were seen more than once for trauma and ordered tetanus immunization (combined) twice; 2 patients before and 2 after the implementation. Both the pre-implementation patients were vaccinated twice, whereas only 1 patient was vaccinated twice in the post-implementation phase and the other patients order was discontinued. While showing a short-term increase in ED based immunization post-implementation of GRITS, real time access to updated immunization records did not impact the overall long- term rates of updating Tdap immunization in the ED. As with many Quality Initiative (QI) efforts, improvements may be transient and further evaluation of GRITS and strategies to maintain the QI impact of this and other EHR systems are important. As suggested by some experts, providing appropriate interactive reminders and alerts at POC to reduce “missed opportunities” to vaccinate during all patient encounters are needed to reach the 90% target of Tdap coverage by 2020 set forth by the government [4].