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The Department of Medicine’s Value-Care Action Group has awarded four value-care improvement projects that will start in July, 2022. Awardees are listed below with overviews of their projects.

Cody Deen, MD: A Chest Pain Transitions Clinic at UNC Hillsborough.

Cody Deen, MD

The management of patients who present to the emergency department (ED) with acute chest pain is a clinical challenge that accounts for approximately 7.6 million annual ED visits in the US. Having a consistent pathway for moderate risk chest pain patients to be seen in a cardiology clinic within 72 hours would decrease hospital admissions and ensure patient safety. This is consistent with the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain which suggests that clinically stable patients with low or intermediate risk be offered shared decision making for safe discharge rather than routine admission. Additionally, these guidelines have fairly detailed algorithms for follow-up testing that are best implemented by a cardiology provider.

This project will develop and implement a chest pain transitions clinic at UNC Hillsborough to provide an alternative to inpatient care for moderate risk chest pain patients, and this will reduce chest pain admissions while simultaneously ensuring timely access to specialized cardiology evaluation. The Chest Pain Transitions Clinic would initially dedicate at least 1-2 appointment slots per day with either a cardiologist or cardiology APP for these patients to ensure available follow up within 72 hours of discharge. This clinic can ultimately serve as a model for similar clinics systemwide.

The project team includes: Cassie Ramm, AGNP-C, Kaitlin Strauss, BSN, Joseph Rossi, MD, and Thelsa Weickert, MD.

Jay Lamba, MD, PhD, and Evan Raff, MD: Deterioration Index (DI) Optimization and Integration to Medical Units.

Jay Lamba, MD, PhD, and Evan Raff, MD

Automated early warning scoring (EWS) solutions are designed to identify subtle signs of patient deterioration to indicate a potentially serious adverse event. However, studies indicate a large number of scoring systems may perform poorly in actual clinical practice and be associated with detrimental effects on patient care due to poor methods in the development and external validation of EWSs. This is thought to lead to the implementation of sub-optimally performing EWSs, “with false reassurance about their predictive ability and generalizability,” with potentially detrimental consequences to the patient.

Optimization of a UNC system-specific DI score is imperative to providing an accurate common language between healthcare providers of all domains. This project team, along with EADS, is working to identify the degree of change in DI score over certain time intervals that may provide the most highly sensitive and specific trigger for pre-emptive RRT consults. The use of the delta DI in this manner will result in more timely interventions, decreased unnecessary transitions to higher levels of care, and decreased cardiac arrest codes outside of the intensive care unit (ICU).

The project team will optimize performance characteristics of the Epic Deterioration Index (DI) score and develop a Tableau dashboard to display a list of hospitalized patients at high-risk for clinical deterioration based on a specified DI score threshold and DI score change velocity (i.e, increase in DI score over time). And by integrating the DI score dashboard into the existing workflow of bedside nurses, rapid response nurses, and physicians can facilitate preemptive interventions on patients who are at an increased risk of clinical deterioration.

The team includes: Hillary Spangler, MD, David Hemsey, MD, Gary Gartner (data scientist– ISD Enterprise Analytics & Data Sciences (EADS), and Clare Kneis (care redesign- Director of Care Redesign UNC System).

Asher Schranz, MD, MPH, and Claire Farel, MD, MPH: Streamlined Care for Persons Hospitalized with Substance Use Disorder-Related Infections.

Asher Schranz, MD, MPH, and Claire Farel, MD, MPH

Patients with substance use disorder-related infectious (SUD-I) are a vulnerable and growing population, and are predominantly cared for on Department of Medicine services. They have extremely long lengths of stay, a low rate of outpatient follow-up, and frequent post-discharge emergency visits. There is a tremendous opportunity to improve length of stay, engagement in outpatient care and prevent further emergency and inpatient care.

This project aims to improve processes and outcomes for patients hospitalized with substance use disorder-related infections (SUD-I), taking a multi-pronged approach to assess and address barriers to discharge, early engagement in outpatient care and prevention of readmission and emergency visits. The project builds on existing quality improvement efforts to transition long antibiotic courses from the inpatient to the outpatient setting (Outpatient Parenteral Antimicrobial Therapy, OPAT) and implement routine engagement of patients in outpatient care immediately following discharge.

Patients with SUD-I are a highly vulnerable patient population with numerous and diverse social determinants of adverse health outcomes. Hence, this project will begin with a slate of initial process improvements and will trial implementing new, focused interventions as additional barriers are identified during the project period.

Based on preliminary data, the team has shown the project meets the Value Care Action Group aim of reducing length of stay, and is expected to reduce post-discharge emergency visits. The work will also inform discharge planning across the Department of Medicine for other groups of psychosocially complex patient populations admitted to medical services.

The team includes Madeline McCrary, MD, Teresa Oosterwyk, RN, and Angela Perhac, PharmD.

Allen Cole Burks, MD: Reducing Length of Stay for Tracheostomy Dependent Prolonged Mechanical Ventilation.

Allen Cole Burks, MD

The length of stay (LOS) of chronically critically ill patients is of particular interest to healthcare systems, especially during the COVID pandemic which has left many systems devoid of resources in terms of physical space and beds as well as the human workforce required to care for these patients. This is compounded by the fact that the pandemic itself has resulted in significantly longer LOS for COVID infected patients, resulting in further reduction in bed space and the ability to care for non-covid related diseases. Regardless of etiology of the chronic critical illness, tracheostomy with prolonged mechanical ventilation (PMV) is a common trajectory for these patients, defined as the need for ≥6hrs per day of mechanical ventilation for ≥21 days.

While there is no clear data to suggest improved survival with an early tracheostomy strategy for respiratory failure, a shorter time to tracheostomy in patients expected to require PMV (those having no serious attempt at ventilator weaning, spontaneous breathing trials, or awakening trials after 5 days on mechanical ventilation) has been shown to decrease ICU and hospital LOS as well as decrease time on the ventilator and overall costs. Although the number of tracheostomies being performed on MICU patients has increased from ~2/month in 2016 to >5/month in the past 5 years, the time to tracheostomy in the MICU is typically >10 days. Factors leading to increased LOS are complex in origin. The broad categories of drivers of LOS in PMV include factors related to patient identification, patient specific factors, inpatient providers, long term care facility availability and capabilities, and overall systems issues.

A weaning strategy is one of many aspects of the patient’s care that can affect length of stay. In 2016, Mr. Mike Garrett of the UNC Respiratory Therapy (RT) department and Drs. Jenny Maguire and Thomas Bice provided a consultative service aimed at facilitating hospital discharge for all UNCMC PMV patients. This team (formerly the Respiratory Optimization and Assistance with Discharge (ROAD) Team”) used a multifaceted approach of ventilator weaning and care coordination for appropriate transfer to LTAC.

This VCAG project proposes to revive and restructure the ROAD team to a new consultative service targeting patients requiring PMV, while expanding the scope to identify potential candidates for early tracheostomy. This new Tracheostomy-ROAD (T-ROAD) seeks to facilitate lower ICU LOS and decrease overall LOS by decreasing time to tracheostomy, initiating weaning protocols, and earlier disposition planning.

The team includes: Jenny Maguire, MD, Kenton Dover, MD, Jason Mock, MD (PCCM), Donna Woods, RT Director, Mike Garrett, RT, Bunny Brown, RT, Honey Jones, DNP, ACNP (PCCM), and Shannon Jones.

About Value-Care Action Group

VCAG encourages the review of current practices, looking for improvements for high-value outcomes in healthcare. High-value is defined by the quality of patient-centered care achieved per unit of cost, derived from measuring health outcomes against the cost of delivering the outcomes. Ron Falk, MD, chair of the department of medicine, created the Value-Care Action Group (VCAG) in 2016 and appointed value-care champions in each medicine division. VCAG projects have included the outpatient diuresis clinic, the inpatient diabetes management service and a patient education initiative that has improved care for cancer patients while reducing unnecessary visits to the ED. Scott Keller is the director of business development keeping the team focused on value-oriented care models. Darren DeWalt, MD, serves as medical director for the team and helps define the projects. John Vargas is the project manager.