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Application of Clinical Intelligence to Streamline Care in Aortic Emergencies

Moats, Susan K. DNP, MBA, RN, NEA-BC; Richard, B. Jeffery MBA, RRT, CPHIMS

CIN: Computers, Informatics, Nursing: October 2017 - Volume 35 - Issue 10 - p 497–504
doi: 10.1097/CIN.0000000000000365

This article discusses the lessons learned by an interdisciplinary team in a large metropolitan specialty hospital during the implementation of the Code Aorta protocol for aortic emergencies and the subsequent application of technological enhancements to improve data transfer. Aortic dissections require rapid diagnosis and surgical treatment; thus, in order to optimize patient outcomes, clinicians must be accessible, data must be readily available, and proper prompts and notifications must be made to alert and ready teams. An interdisciplinary team reviewed our hospital’s processes and architecture of systems to define how we provide care during aortic emergencies. Based on this insight into patient flow, we ultimately developed a Code Aorta protocol to streamline provision of care during aortic emergencies. This process focused on protocol development, human-technology interfaces, and outcome-oriented metrics. The team also aimed to heighten awareness of the emergent process and to understand relevant outcomes data. After introduction of the Code Aorta protocol, a 78% reduction was achieved in time-to-treatment from the previous year’s average time. In addition, the average length of stay was reduced by 2.4 days (18%). The team’s efforts focused on clinical communication, aiming to link technology to maximize clinical efficiency. The initial results of our Code Aorta protocol show promise that continual refinement of patient care processes during aortic emergencies will improve outcomes for patients suffering aortic dissection.

Author Affiliations: Texas Christian University, Harris College of Nursing and Health Sciences, Fort Worth (Dr Moats); and The Heart Hospital Baylor Plano and The Heart Hospital Baylor Denton, Texas (Mr Richard).

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Susan K. Moats, DNP, MBA, RN, NEA-BC, Texas Christian University, Harris College of Nursing and Health Sciences, TCU Box 298627, Fort Worth, TX 76129 (

Transforming care delivery through focused strategies using evidence-based practice and internal opportunities to promote better care outcomes begins with a vision.1 The shared vision of any healthcare organization should be to improve the quality of care, which can be achieved by optimizing information transfer to increase efficiency and enhance patient outcomes. Even in this modern era of data analytics and improved technology, however, the topic of efficiency in systems integration remains somewhat nebulous in most healthcare institutions.

Improving patient access to care is a cutting-edge initiative that requires improvement in care quality and effective processes. A process is a combination of activities within an enterprise that has a structure to describe its logic and dependence.2 Process modeling facilitates common understanding so that a more comprehensive overview of the entire process can be obtained. Clinical pathway processes are structured multidisciplinary care plans used by health professionals to outline necessary steps in the care of patients with specific clinical problems. New technology has made the transmission of multifaceted data and information possible. Harrington3 describes clinical intelligence (CI) as the process of translating data from multiple clinical sources into information and subsequently into knowledge or outcomes. Unfortunately, connections between clinical environments and CI technology, or the “human-technology interface,” are often limited even in the modern hospital. Therefore, understanding clinical processes and how CI technology can be incorporated to improve workflow may be necessary to improve clinical pathway processes.

Successful implementation of clinical pathway processes in healthcare has offered much in achievement. For example, the treatment of ST-segment elevation myocardial infarction over the past decade has evolved significantly because of the attention that has been drawn to the door-to-balloon (D2B) times. A shorter D2B time represents more rapid reperfusion of the affected coronary artery and thus has been linked to a decrease in myocardial damage and reduced mortality rates.4 In order to decrease D2B times, many healthcare facilities have implemented clinical pathway processes designed to streamline patient flow from arrival through evaluation in the emergency room and into the catheterization laboratory.

At our institution, an interdisciplinary team was recently formed to systematically assess the needs of patients with emergent aortic disease, whose similar needs for timely intervention and access to care are a matter of life or death. The vision of this team was to improve patient outcomes in aortic dissection by developing evidence-based protocols and use CI technology to streamline care and integrate clinical pathway processes. The goals of the team were to (1) develop an evidence-based protocol to treat patients who were referred with acute aortic syndrome, (2) implement CI tools to transfer information and streamline care pathways in aortic emergencies, (3) ensure highly coordinated multidisciplinary care, and (4) integrate existing technologies to support care delivery. Herein, we discuss the process taken by the team to apply CI technology toward driving clinical algorithms and patient flow to improve outcomes.

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Ascending aortic dissection is associated with a severely high mortality rate of approximately 23% within the first 24 hours, 50% within 48 hours, and 75% within 2 weeks of initial diagnosis.5 In addition, postoperative mortality rates of ruptured abdominal aortic aneurysms range from 40% to 50% and can be as high as 90% if patients with a ruptured abdominal aortic aneurysm die before they arrive at the hospital.6 Of concern is the fact that no standard guidelines for transfer of acutely ruptured aneurysm exist in the United States.7 In a recent survey of physicians in hospitals that receive emergency aortic patients, it was found that 60% of facilities do not have a formal protocol for treatment of aortic emergencies, and 70% of facilities do not use transfer protocols or clinical guidelines.8 While recent clinical and technological advances have improved mortality rates for both of these aortic emergencies, the national average for postoperative mortality remains exceedingly high.9

Aortic emergencies can be difficult to recognize, and delays in diagnosis may be fatal. A high level of clinical suspicion and rapid patient evaluation are vital. Although many patients ultimately require surgical intervention, few facilities have treatment capabilities and skilled cardiothoracic and vascular surgeons that can surgically intervene and support these patients. Notably, early attention and treatment can safely increase the window to treatment, allowing for transfer to tertiary facilities capable of complex patient management.10 Therefore, it is critical that all interfacility teams have the ability to quickly recognize aortic emergencies and transfer the patient to an appropriate facility.

As previously discussed, for patients with a myocardial infarction, D2B is a quality metric that has stimulated substantial reductions in time delays for primary percutaneous coronary intervention across many systems. The implementation and tracking of D2B over the last decade demonstrate the power of understanding processes. Clinical guidelines and national quality initiatives have thus focused on shortening D2B times over the past decade. Significant progress has been made in reducing national mean D2B times from 86 minutes in 2005 to 63 minutes in 2011 (P < .0001). This reduction in mean D2B has been matched by a concurrent decrease in risk-adjusted 6-month mortality (from 14.4% to 12.9%; P = .001).11 At our own specialty institution, the D2B times have decreased from 90 minutes in 2009 to 50 minutes in 2015.12

Recognizing the importance of team collaboration and coordination in process reviews to achieve this reduction in D2B at our institution, the aortic interdisciplinary team applied similar logic to enhance our understanding of clinical processes and gain new knowledge to define a quantitative outcome metric to assess efficiency of care delivery during aortic emergencies.

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As described by McGonigle and Garver-Mastrian,13 clinical knowledge can be derived from technologies only if they offer accessible, timely, and accurate information. This article introduces the Foundation of Knowledge Model as a conceptual framework while also utilizing the Model of Nursing Informatics integrated into medical and nursing sciences. The Foundation of Knowledge Model consists of four main components for applying and implementing knowledge to form a foundation of process improvement that relies on data acquisition to transform knowledge into a new product. First, knowledge acquisition, or understanding workflow processes, was completed to understand the patient flow within existing systems. Second, knowledge dissemination was performed to enable opportunities to enhance clinical algorithms, explore opportunities, and identify metrics that allow for ongoing learning. Third, knowledge generation, the team’s new knowledge, motivated changes in the current infrastructure to expand information to other teams. Finally, knowledge processing, the use of systems data to gain insight into change management and metrics, was implemented to improve processes. By using the Foundation of Knowledge Model in the assessment of the workflow process during aortic emergencies, all components of this process can continue to evolve as methods improve, and the team’s knowledge expands.

Information is the foundation of any patient flow initiative. Understanding the movement of information will assist in taking the process from one that is static to one that is dynamic. However, most information transfer and integration include many steps and processes that can be easily overlooked. Team development and team assessment of the issues must be a part of the process change. Understanding how change affects people is a necessary issue that must be addressed by healthcare teams in process change management.14 Thus, our objective was to have all team members capture patient flow patterns in their current environment.

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The Aortic Center is aligned with The Heart Hospital Baylor Plano in Texas and provides comprehensive treatment for a full range of aortic conditions. Commitment to a shared vision for the Aortic Center with a focus on quality and resources was identified upon inception. In addition, a strong motivation to provide access to specialized care and improve patient outcomes was a major motivator for the team. At inception, our interdisciplinary team committed to a system of collaboration with the goal of building such an algorithm for treatment of aortic emergencies including patient transfers, a protocol we termed “Code Aorta.” Following the development of protocol and project metrics, the institutional review board examined this project, defined it as a process improvement, and granted its exemptions.

The Foundation of Knowledge Model has four components that dictated the methodology that was utilized in this process improvement.

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Knowledge Acquisition

A key point to note is the cooperation within this process team and among the independent parties involved. The quality of health outcomes is dictated by collaboration across professional boundaries, joint ownership of decisions, and collective responsibility.15 Communication among interdisciplinary teams involving surgeons, administrators, transfer teams, nursing staff, informatics staff, and emergency and operating staff is key to the inception and execution of programs in complex healthcare environments.

Following a literature review, discussion with physician champions identified clinical symptoms pertinent to diagnosis of aortic emergencies as well as treatment plans to generate a decision tree and ultimately a treatment algorithm for this patient population. Our team identified intake tracks and systems used in each step of the process. The teams also built and defined awareness of the clinical symptoms of aortic disease and triggers in criteria for suspicion that can be acted upon by nonexperts. The team also established the need for early recognition and rapid transport to a facility with the skill set to deliver the intensity of service and surgical intervention. A strong focus was placed on the ability to capture patient information and disseminate it quickly in order to influence outcomes through decreased time to transfer and early initiation of therapies.

Because this is a large tertiary referral center, the majority of the emergent aortic interventions come from an external source. Because timeliness of transfers has an impact on outcomes and referrals, the careful review of external systems was evaluated in transfers once the care algorithm was completed. Our facility uses a centralized transfer center to facilitate transfers within a large metropolitan area. The objective is to minimize clinical questioning during the transfer process while engendering a relationship between facilities without compromising diagnosis and treatment. As a result, a specific line of questions related to imaging, physiology, and laboratory values was created to diagnose and minimize duplication of services.

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Knowledge Dissemination

Next, internal functionality was reviewed, and a noted deficiency in orders and workflow was identified: notably, a lack of a streamline process to facilitate diagnosis, admission, and management of the emergent aortic patient. Specifically, the informatics specialist determined that standardized orders for aortic emergencies were not developed in the electronic health record. Previous research demonstrates that implementation of standardized order sets, templates, or protocols can improve compliance and patient outcomes with recommended processes of care. For example, standardized order sets for postoperative weaning and extubation of cardiac surgery patients have led to decreased time in the ICU, as well as a decrease in postoperative variability in care.16 As a result, clinical informatics specialists, physician champions, and advanced practitioners created and implemented an order set based on current evidence-based guidelines in the clinical documentation system using evidence-based practice guidelines and safety metrics to expedite the care and treatment. Following approval, the order sets were disseminated to all physicians via an electronic format, which allowed for ease of order entry and quick implementation at the point of entry within the clinical documentation system. It also allows for a patient who did not meet criteria for surgical intervention to begin medical treatment and management at the entry.

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Knowledge Generation

The review of informatics and technological systems in the current processes was evaluated. The team focused on the capture and integration of information in the current system. The plan was to integrate existing systems used in other workflows to enhance care with an overall goal of enhancing the use of all available technologies. Examples of existing systems used by staff members include pagers, cell phones, fax systems, scheduling systems, clinical documentation systems, and admission discharge transfer systems. During the examination, there was a notable variation in processes from physician to physician and between staff members in not only access to but also transfer of data and information. While any process contains variability in workflow, it may cause delays while decreasing predictability and utilization.14

Two current systems, already used for other purposes outside aortic emergencies, were engaged in this process to enhance communication. Of these systems, neither had previously been utilized in a system care algorithm or the treatment of emergent care conditions. One is a HIPAA-compliant image-share technology. This image-share technology can facilitate the exchange of test results between patients, other hospitals, freestanding faculties, physicians, and other clinicians. Patients typically provide prior medical imaging studies on compact discs. Accessing the studies can be difficult and time consuming, and if discs are lost, damaged, or not in the correct format, unnecessary repeat scans might be required. With this image-share technology, physicians can view outside studies as easily as those performed within the home facility. Once loaded into the cloud-based technology, studies and reports can be shared with other users on the network (Figure 1).

The second system implemented in the care path is the solution that brings together all channels and devices, to communicate and collaborate critical events. It should be noted that the system that is utilized at our aortic center is certified by the Department of Homeland Security for its level of security. It has flexible deployment options to all for configurable alerts to multiple groups that safeguard important information and enables enterprise-level command and control across a widely dispersed enterprise. It allows for use on multiple platforms, such as e-mail, text, and voicemail, and setting user preferences. This crisis management alert system is a solution designed to provide emergency alert management and can be incorporated for use in multiple workflows. Along with specific messages to specific groups, the call system can also target specific workstations to the general end-user community. It is being used successfully to notify end users of system degradation and major incident management for our information-specialist partners to notify technical first responders. The Code Aorta groups were added to this care algorithm to quickly communicate the need to mobilize and the tentative strategy to end users (Figure 2).

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Knowledge Processing

The informatics team we used to demonstrate implementation of technology reviewed all systems. Valuation of the protocol and processes was set up in testing mode for all informatics modality introduced to the process. The informatics team brought a solid technical understanding of system integration and software application. In addition, the informatics specialists were instrumental in understanding systems related to existing infrastructure and understanding of utilization and capabilities. This knowledge is expanding the boundaries of all team members in the application and usability of systems.

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The Code Aorta protocol was initiated on January 4, 2016, and the time assessed for this report includes the first year following implementation. The metrics established were door–to–operative suite time and length of stay. These data points were noted to be first steps in the development of a more robust data set. All types of aortic emergencies were included in the review. However, only those cases that went to the operating room are included in the reported metrics in order to ensure that only emergent transfers, and not urgent transfers, were included in the analysis.

In 2015, the baseline metrics studied for this process were noted to be 6.11 hours on average as the time from arrival to the operative suite, and the average length of stay was 13.59 days (Figure 3). In the analysis following the go-live on January 4, 2016, we divided the metrics into two groups for time assessment. Of the 63 patients evaluated, Group A (29 patients) included patients for which the Code Aorta process was utilized, and Group B (34 patients) received the usual standard of care (Figure 3). Patient demographics are illustrated in Figure 4.

The data demonstrate a significant decrease (97%) in time to operative suite and length of stay in the Code Aorta (Group A, 1.68 hours) versus the standard of care (Group B, 55.08 hours). Following implementation of Code Aorta, length of stay was also noted to decrease in Group A (11.12) versus Group B (12.67). It is hypothesized that the efficiencies established in the Code Aorta process also contributed to the non–code Aorta Group (B) reduction in length of stay from the previous data set. The data and results need to be further explored to understand treatment times. Mortality for Group A was noted at 14% (four of 29) and for Group B at 21% (seven of 34).

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Although still considered relatively “new,” the adoption of a general protocol for accurate follow-up is necessary in order to critically evaluate the progression and effectiveness of the care plan and technology utilization. The activation of Code Aorta was noted to be used in less than 50% of the cases in the previous year; however, adoption continues to increase throughout the project with dissemination of results.

Improvements in outcomes and times to surgical intervention are the result of the progressive implementation of evidence-based practice and optimal use of technology at multiple levels. The process has been iterative, and learning from each case has assisted in understanding the many complexities associated with transfer of emergent aortic patients. The successful initiation of our Code Aorta process was due to the team’s ability to make changes and learn more about how the systems interact at all levels.

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A limitation of this review is in the small number of patients for which Code Aorta was initiated, which may be attributed to the early onset of programmatic implementation. However, the data mirror the results reported by Mell et al,7 which note that most facilities, although capable of intervention, lack the formal treatment protocols and transfer algorithms for timely treatment and use. Continued refinement of system processes and internal communications did assist in use of protocols and improving overall effectiveness. Despite the challenges in initiation of the new standardized process, with the data confirming efficiency and outcomes, the project has gained acceptance by all providers. The process was also limited by the fact that it was performed at a single institution.

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Institutions implementing programs for timely referrals and treatment require knowledge of systems and the ability to institute systematic protocols. Communication among the multidisciplinary teams involving surgeons, informatics, administrators, transfer teams, nursing, emergency staff, and the operating team is fundamental to inception and execution. Integral to any new process is the inclusion of the informatics team, as workflow analysis is not an optional component of clinical implementations.

The significance of incorporating technology and evidence-based practice to treat patients in aortic emergencies cannot be understated. Harris et al17 proposed that an earlier diagnosis of aortic disease and initiation of decisive treatment are associated with improved outcomes, and implementation of systematic rapid operative approach can improve metrics. Incorporating the informatics team into the multidisciplinary team increases the understanding of how existing software can aid information transfer and process variation. Incorporating informatics professionals into the process of clinical evaluation and efficiency improvements is often overlooked but is imperative to any workflow optimization today. Further examination of data and outcomes must be studied to understand the benefit of integration using clinical and technical workflows in this type of setting and others.

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Improving patient flow requires a vision for enterprise-wide improvement together with a multidisciplinary team that includes those knowledgeable in clinical and technical operations and a process that is iterative in nature. Establishing the right team to interpret and design proper data on patient flow is an important key to influencing and sustaining improvements. Even with well-charted and mapped processes and despite the influx of more data, we are still improving our picture of the entire process and knowledge on technological workflows. Building systems to communicate and expedite care takes time and effort to understand not only the software but also data flow and human-technology interactions. Human interfaces can differ each time in a process, and understanding how this influences the process, data, and outcomes is critical to streamlining care. Despite the emphasis on development and dissemination of practice guidelines, remarkable variation persists in the provision of healthcare. Standardization is a term commonly used today in healthcare, but in our experience, many users interact with systems differently. Having processes and data intuitively that meet the clinical teams where they are is important to gaining consensus on its specialty.

This ongoing project aims to utilize the data collected and continues to refine the process and measures, as well as seek opportunities to expand capabilities. We believe our efforts will assist in not only enhancing clinical outcomes but also increasing awareness and giving informatics professionals a greater role in the clinical design and improvement in overall patient outcomes and quality of care. As stated by McGonigle and Garver-Mastrian,13 when technology is implemented well, it is likely to achieve greater patient outcomes and safety benefits.

The amount of data and system proliferation is vastly changing the landscape in healthcare. Understanding clinical data coupled with optimizing interoperability and the use of CI is critical to improvements in care and patient flow. Such applications result in enhanced safety and increased efficiency by significantly reducing the chance of error caused by reliance on memory, limited access to information, and a lack of care standardization and training. This article demonstrates use of informatics tools in expediting care to critically ill patients and utilizing a multidisciplinary team in its design and operations. The experience gleaned in this study can be used as a reference for other hospitals with similar technology and services to drive outcomes. Institutional teams play a key role in leveraging technologies to improve the timeliness and quality of patient care. The proliferation of systems and enhanced technological capabilities allow CI to deploy innovation in processes. The synergy that is created in new knowledge will meet the needs of patients, improve delivery of care, and ultimately improve the health of our communities we serve.

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Aortic aneurysm; Aortic dissection; Clinical intelligence; Efficiency; Interdisciplinary communication

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