Terry Platchek

Safety analysis of proposed data‐driven physiologic alarm parameters for hospitalized children

INTRODUCTION Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values. METHODS In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits. RESULTS There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context. CONCLUSIONS A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823.

Time-driven activity-based costing of multivessel coronary artery bypass grafting across national boundaries to identify improvement opportunities: study protocol.

Introduction Coronary artery bypass graft (CABG) surgery is a well-established, commonly performed treatment for coronary artery disease—a disease that affects over 10% of US adults and is a major cause of morbidity and mortality. In 2005, the mean cost for a CABG procedure among Medicare beneficiaries in the USA was

Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness

32 201±

Hospital-Affiliated Outpatient Birth Centers: A Possible Model for Helping to Achieve the Triple Aim in Obstetrics

23 059. The same operation reportedly costs less than

Better Health, Less Spending Delivery Innovation for Ischemic Cerebrovascular Disease

2000 to produce in India. The goals of the proposed study are to (1) identify the difference in the costs incurred to perform CABG surgery by three Joint Commission accredited hospitals with reputations for high quality and efficiency and (2) characterise the opportunity to reduce the cost of performing CABG surgery. Methods and analysis We use time-driven activity-based costing (TDABC) to quantify the hospitals’ costs of producing elective, multivessel CABG. TDABC estimates the costs of a given clinical service by combining information about the process of patient care delivery (specifically, the time and quantity of labour and non-labour resources utilised to perform each activity) with the unit cost of each resource used to provide the care. Resource utilisation was estimated by constructing CABG process maps for each site based on observation of care and staff interviews. Unit costs were calculated as a capacity cost rate, measured as a

Improving Communication with Primary Care Physicians at the Time of Hospital Discharge

/min, for each resource consumed in CABG production. Multiplying together the unit costs and resource quantities and summing across all resources used will produce the average cost of CABG production at each site. We will conclude by conducting a variance analysis of labour costs to reveal opportunities to bend the cost curve for CABG production in the USA. Ethics and dissemination All our methods were exempted from review by the Stanford Institutional Review Board. Results will be published in peer-reviewed journals and presented at scientific meetings.

Systems delivery innovation for Alzheimer's disease

Adolescents and young adults (AYA) with serious chronic illnesses face costly and dangerous gaps in care as they transition from pediatric to adult health systems. New, financially sustainable approaches to transition are needed to close these gaps. We designed a new transition model for adolescents and young adults with a variety of serious chronic conditions. Our explicit goal was to build a model that would improve the value of care for youth 15-25 years of age undergoing this transition. The design process incorporated a review, analysis, and synthesis of relevant clinical and health services research; stakeholder interviews; and observations of high-performing healthcare systems. We identified three major categories of solutions for a safer and lower cost transition to adult care: (1) building and supporting self-management during the critical transition; (2) engaging receiving care; and (3) providing checklist-driven guide services during the transition. We propose that implementation of a program with these interventions would have a positive impact on all three domains of the triple aim - improving health, improving the experience of care, and reducing per capita healthcare cost. The transition model provides a general framework as well as suggestions for specific interventions. Pilot tests to assess the models ease of implementation, clinical effects, and financial impact are currently underway.

Birth Center Model of Care

At nearly 4 million deliveries each year, birth is one of the most common reasons women are hospitalized in the United States.1 Costs for US maternity care are among the most expensive in the world. A comparison by the International Federation of Health Plans, which represents 80 health insurance companies in 25 countries, found that payments for vaginal deliveries in the United States (

Implementation of Data Drive Heart Rate and Respiratory Rate parameters on a Pediatric Acute Care Unit.

17 354) were substantially greater than those of the next highest ranked country (Switzerland,

Lean Health Care for the Hospitalist

8307).2 In addition, despite a greater cost for delivery in comparison with most other OECD (Organisation for Economic Co-operation and Development) countries, the US cesarean delivery rate is higher,3 without better birth outcomes. Worldwide, the United States ranks 48th in maternal mortality4 and 57th in infant mortality.4 The United States could improve outcomes and decrease costs by reconsidering where low-risk deliveries take place. Although hospitalization for childbirth has become routine in the United States, many pregnant women do not need expensive inpatient treatment. A new national model of maternity care that mirrors a model that has already been successfully and broadly implemented in the United States—ambulatory surgical centers closely affiliated with a hospital—is needed. In this Viewpoint, we propose development of a nationwide network of hospital-affiliated outpatient birth centers that could improve the experience, quality, and affordability of care for pregnant women. The announcement in 2014 by the United Kingdoms National Institute for Health and Care Excellence that women who delivered in midwifery units or birth centers had the same maternal and neonatal outcomes as a similar population delivering in hospitals5 reactivated discussion about whether such birth centers might be appropriate in the United States. Although US birth centers have existed for decades, only 0.4% of births currently take place in the approximately 300 existing freestanding facilities.6 There are several explanations for this lack of broad adoption. Most freestanding birth centers in the United States function as isolated businesses, and it is not clear whether they have highly sophisticated and efficient collaboration protocols with inpatient clinicians and hospitals. Inadequate integration risks morbidity and mortality during obstetrical emergencies when rapid access to hospital obstetrical units with in-house obstetricians is essential. Many obstetricians vividly recall anecdotal cases involving devastating delayed transfer experiences—cases that may have an influence on their perception of all out-of-hospital births. Inconsistent regulation of birth centers poses another problem. Only 104 birth centers have accreditation by the Commission for the Accreditation of Birth Centers, whereas others do not. In some existing centers, variability in education and licensure among midwives, the primary caregivers, creates potential concern about the quality of care provided. Difficult issues with integration, regulatory oversight, and perception enable easy dismissal of birth centers as a viable option in the United States, but current evidence suggests that these centers could offer many women real advantages. For example, in the planned and integrated system in the United Kingdom, perinatal morbidity and mortality and maternal morbidities among women and their children at low risk of perinatal complications are not significantly different when compared between planned births at birth centers vs hospitals.5 Moreover, patients in the United States are increasingly demanding a birth experience that provides interventions only when necessary. Women with low-risk pregnancies who plan to deliver in birth centers are less likely to undergo interventions such as operative deliveries or episiotomies compared with those who deliver in a hospital setting.5 Cost is also an important consideration. Payments to birth centers in the United States are roughly half the amount of payments to hospitals for a vaginal delivery because there is no hospital overhead cost. As a society with increasing health care costs, it makes little sense to pay for inpatient care for women who neither need nor want it. The key components of the outpatient birth center model are based on appropriately risk-stratified patients; strong integration with a health care delivery system; and dedicated, around-the-clock, newborn delivery support. Women would be eligible to deliver in an outpatient birth center after careful screening using strict criteria that defined them as low-risk patients such as those used in the United Kingdom.5 Eligible women and their obstetrician-gynecologists or midwives would evaluate this option through a shared decision-making process, considering preferences for pain management and obstetric care practices. Risk is a critical consideration. As every obstetrician and midwife knows, a woman with a low-risk pregnancy can have an uneventful delivery and suddenly experience a serious complication such as severe postpartum hemorrhage—requiring immediate operative attention. Yet many hospitals’ safety standards have room for VIEWPOINT