Poke-R

Using Analytics to Reduce Patient Harm

James P. McGlothlin

, Evan Crawford

, Jesse Wyatt

, Carlos Samayoa

, Yana Vaks

Brenda Bruneau

, Merrick Lopez

, Anthony Moretti

, Michele Wilson

and James Pappas

Fusion Consulting Inc, Irving, TX, U.S.A.

Loma Linda University Health System, Loma Linda, CA, U.S.A.

Keywords: Data Warehousing, Healthcare Analytics, Quality, Pediatric Intensive Care, Business Intelligence.

Abstract: Major events and surgeries are not the only sources of trauma during a hospital encounter. Many small, less

invasive events such as shots, line placements, blood draws, and imaging studies happen throughout a

patient’s hospital stay. Many of these less traumatic events have the potential to negatively impact patient

outcomes by increasing the risk of hospital-acquired infections through skin invasions and exposure to

organisms, reducing the patient experience by causing pain and frustration, increasing cost and causing other

complications. The goal of this project is to reduce such events when they are not clinically required. This

is an analytics project so this goal is facilitated by making accurate and meaningful information available to

the appropriate personnel. This includes timely information to clinicians so they can alter treatment, and

retrospective trend analysis to enable and track performance improvement and identify opportunities for

additional process improvement.

1 BACKGROUND

This project is based on the Prevent Pain and

Organisms from sKin and catheter Entry (POKE)

project initiated at Dixie Regional Medical Center.

Dixie Regional implemented the POKE initiative

within their Neonatal Intensive Care Unit (NICU)

(Ridout, 2014). The results at Intermountain Health

System show that the POKE project has resulted in

reduced POKEs for NICU patients and significant

financial savings estimated at $3.5 million over 5

years for a single hospital. Reduction in length of stay

was also identified. Figure 1 and Figure 2 quantify

cost reduction associated with the original Dixie

Regional Medical Center project.

We are calling our project POKE-R because we

are including Radiology events. Radiology images

can cause serious complications later in life for

pediatric patients due to the much higher sensitivity

children have to radiation, and also reduce

patient/parent experience (Medscape, 2014) (Slovis,

2002) (Brenner, 2002). We are leveraging this prior

research and enhancing it. We are considering

anything a POKE which invades the skin or opens a

line or drain into the patient. This includes

medication administrations, blood draws, placement

of lines, drains and airways (LDAs), surgeries, and

other invasive procedures.

The goal of our project is to reduce POKE-R

events by providing detailed information to the

clinicians. Often lab draws or procedures are not

medically necessary and may cause more harm than

good (Salisbury et al, 2011). Also, many times lab

tests can be combined to use a single specimen

collection. A patient sees many providers throughout

a hospital stay and there may be redundant orders or

orders which are no longer medically warranted.

Figure 1: Hospital savings experienced by Dixie Regional

Medical Center POKE initiative.

362

McGlothlin J., Crawford E., Wyatt J., Samayoa C., Vaks Y., Bruneau B., Lopez M., Moretti A., Wilson M. and Pappas J.

Poke-R - Using Analytics to Reduce Patient.

DOI: 10.5220/0006174603620369

In Proceedings of the 10th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2017), pages 362-369

ISBN: 978-989-758-213-4

Figure 2: Patient savings experienced by Dixie Regional

Medical Center POKE initiative.

By reducing POKEs we hope to achieve each of

the following potential improvements:

 Reducing hospital-acquired infections

Every time a patient’s skin is punctured, line is

opened, or catheter is placed, there is an increased risk

of a hospital-acquired infection. For example, there

is significant evidence that risk of Central Line

Associated Blood Stream Infections (CLABSI) is

increased by repeated blood lab draws (Foster and

Sabella, 2011) (Grissinger, 2011) (Sengupta et al,

2010).

 Improving the patient experience and the

satisfaction of the patient and his/her family

The pain caused by invasive procedures, shots,

and placement of lines, drains and airways has a clear

effect on the patient experience and satisfactions.

 Reducing anemia, blood loss and blood

transfusions

Each time blood is removed from a patient to

perform a lab test, there is an increased risk of side

effect or even the need for a blood transfusion. This

is particularly prevalent with neo-natal patients and

young pediatric patients and also with acute

myocardial infarction (AMI) patients (Bateman et al,

2008) (Salisbury et al, 2011) (McVoy and Shandler,

2013)

 Reducing complications from radiology

Radiology imaging have been connected to

complications for pediatric patients including cancer.

Children have a greater sensitivity (10 times more

than a middle aged adult) to radiation dose and

computed radiography. Furthermore, the necessary

movement required for a radiological exam can

increase risks of further injury or disrupt lines, drains

and airways (Foster and Sabella, 2011) (Brenner,

2002). Finally, the physical methodology of many

imaging procedures, such as MRIs, can cause

psychological trauma and reduce the quality of the

patient experience.

 Reducing length of stay

Reducing POKEs has been shown to reduce the

median length of stay for neonatal patients.

Furthermore, POKEs increase the risk of infection,

and hospital-acquired infections dramatically

increase average length of stay for patients (Alharfi et

al., 2014) (Foster and Sabella, 2011).

 Reducing cost

All procedures performed incur costs so the

simple act of reducing the number of procedures

directly reduces costs. Costs are also indirectly

reduced through reduction in hospital-acquired

infections and reduced length of stay.

The principle behind our approach is value-based

medicine. The concept is to focus practice on patient

and financial value of the medical interventions. The

goal is to incorporate the highest level of evidence

based interventions while ensuring adequate patient

care and minimizing healthcare costs (Bae, 2015).

2 TECHNICAL

IMPLEMENTATION

At Loma Linda, we have an enterprise data

warehouse sourced from the clinical data in the Epic

Electronic Medical Record (EMR) System. We

implemented the POKE-R process by using the

information in this data warehouse to build a new

POKE-R fact table using standard industry

dimensional modelling data warehouse practices.

The foundation for the data warehouse is provided

by the EMR vendor, but we have extended it to

include more detailed information useful for this

project including

a) Lines, drains and airways

Needed to determine when a LDA was placed and

when it was removed.

b) Procedure performance details

Needed to know if a procedure or image was

actually performed, by who and when

c) Medication Administration Route

Needed to know how a medication was

administered

Additionally, we had to add two extensions

specifically for this project. We added an extension

and modified EMR workflow specifically for LDAs

to know how many attempts the LDA placement took.

Furthermore, physician-performed LDAs such as

central lines were documented in a different manner

so we created a special extract to get the placement

times and attempts. Finally, it was not enough to

know when a specimen was taken. We needed to

know which procedure orders shared blood draws and

Poke-R - Using Analytics to Reduce Patient

363

which required separate blood draws. If 5 lab draws

show the same collection time, it is important to know

whether they were separately drawn, or all of the tests

used the same blood collection.

With these extensions, all of the data needed to

mine the POKE-R information was available in the

data warehouse. However, before we could search

for the POKE-R events, we had to configure which

events were defined as POKEs. We did not want to

hard-code this information and we did not want the

information determined or maintained by IT

personnel as it is clinical in nature. Therefore, we

established an interface to configure POKE-R.

We needed to define every event which was a

POKE-R event and whether it was painful. This

needs to be configured using attributes of the data

elements. The following attributes were identified by

the clinician as identifying POKEs:

1. Medication Administration: Route and

Administration Event

2. Lab Test: Specimen Type and Specimen

Source

3. Procedure Order: Type and Code

Additionally, the presence of a line or drain prior

to the event can impact whether the event is a POKE

and whether it is painful. For example, blood tests

and medication administrations are considered non-

painful if they use an existing line. A urine sample is

not a POKE at all unless there is a catheter used to

obtain the specimen.

Finally, if the patient is under anesthesia at the

time of the event, it is considered non-painful.

We created a simple secure interface for the

Patient Safety and Reliability leadership to provide

and administer this clinical information. This

interface contains the data points listed above

prepopulated from the actual clinical data warehouse.

The user can then choose which values for each data

point indicate a POKE and can combine data points.

We developed software code using Microsoft

SQL Server Integration Services (SSIS) to read the

POKE-R configuration file and then extract POKE-R

events from the data warehouse into a new table

within the data warehouse called PokeFact. This fact

table contains the following information:

1. Encounter ID: The encounter the POKE

happened during

2. POKE type: LDA Placement, LDA

Placement Extra Attempts, Medication

Administration, Image, Specimen Collection, Point

of Care Test (POCT), Invasive Procedure, Surgery

3. Whether the POKE has already happened

or is scheduled to happen in the future

4. When the POKE was ordered

5. The provider who ordered the POKE

6. When the POKE was scheduled to occur

7. When the POKE occurred

8. Whether the POKE is painful

9. Who performed the POKE

One thing that was very important was to

determine the scheduled POKE-R events. Our goal

was to show the clinician the upcoming POKE-R

schedule so that treatment could be altered to reduce

the POKEs. To do this we brought in every scheduled

medication administration, procedure, surgery, image

or lab test.

3 INFORMATION

PRESENTATION

At this point, we had aggregated all of the information

necessary to analyze POKE-R. The next step was to

make this information useful to a clinician.

We developed three reports. The first report was

a detailed report of patients currently in the hospital.

This report lists for each patient the total number of

pokes and painful pokes, the number of pokes and

painful pokes in the last 7 days and the number of

scheduled pokes for the next 3 days in graphical

format. This poke counts are then shown grouped by

the type of poke. Finally, every POKE performed in

the last 7 days and every POKE scheduled for the next

3 days was individually listed with details. This

reported was filtered by department so that an

individual department could see each patient in the

department. Scheduled POKEs are not always ever

performed or cancelled. They can be left in pending

status. So we dropped any scheduled POKE in the

past which was never performed. The second report

was the abridged version of the first report, showing

only the number of POKEs over the past 7 days and

what POKEs were scheduled for today. This made it

more simpler for clinicians to digest the POKE-R

information and make actionable decisions. Figure 3

shows an example of this report.

The third report was a trend of POKEs per Patient

per Day over time so we could see if performance

improvement was being achieved. This report was

able to be filtered by location, unit, or attending

provider. Figure 4 shows an example of this

retrospective report.

Together, these reports enable process

improvement and improved treatment. The provider

and treatment team are supported by the detailed

report, while the analysts in Patient Safety and

Reliability have the aggregate and retrospective

information to identify improvement opportunities.

HEALTHINF 2017 - 10th International Conference on Health Informatics

364

Figure 3: Example of abridged Patient POKE-R report.

Figure 4: Example of POKE-R trend report.

Poke-R - Using Analytics to Reduce Patient

365

4 PROCESS IMPLEMENTATION

To pilot the program, we chose a single department,

the Pediatric Intensive Care Unit (PICU). We chose

this department specifically because of the increased

risk of complications in critical care pediatric patients

including anemia and infection (Bateman et al, 2008)

(Ridout, 2014) (Sengupta et al, 2010). The abridged

report was scheduled to be automatically printed in

the PICU at 5 am every morning so clinicians could

(r to most POKEs being performed for the day. A

resident fellow and a clinical nurse specialist were

assigned specifically to manage the implementation

of the program and received the daily detailed report.

This allowed them to examine the most critical

patients and suggest opportunities for POKE-R

reduction.

At Loma Linda, the PICU uses structured

interdisciplinary bedside rounds (SIBR). Under the

SIBR methodology, all members of a patient’s care

team visit and communicate with the patient as a unit.

Figure 5 shows the SIBR methodology. Because the

SIBR methodology includes careful review of lab

work, it provides a perfect opportunity to address

potential POKEs. We have adjusted the SIBR

methodology to include POKE-R.

The methodology includes:

1. Discuss and justify each care intervention.

2. Choose interventions that are:

 Supported by evidence (consider pre-test

probability)

 Lead to change in treatment plan

 Lowest cost

3. Considers cost in terms of financial burden and

patient experience

 Deliver best possible care, at the lowest

cost to the healthcare system and the

patient.

 Reduction in patient harm, exposure,

and pain are all considered.

4. Minimize ordering labs, instead perform a risk

vs. benefit analysis for each test

Please see Figure 6 for an illustration of the SIBR

POKE-R approach.

Additionally, three sets of patients were targeted

as providing significant opportunity and actively

managed using the daily report. These were patients

with traumatic brain injury (TBI), patients with

asthma and patients with external ventricular drain

(EVD) placements. These patients are especially

susceptible to infections and complications (

Alharfi et

al, 2008)

. Furthermore, asthma patients often

experience an excessive number of lab tests in order

to monitor the effects of medication on patient

potassium levels (Schuh et al, 1989). Traumatic brain

injury patients often experience sodium instability

which requires monitoring (Atchinson et al, 1993).

Therefore, these patients are likely to have a

substantial number of POKE-R events and are

particularly vulnerable to harm from these events.

Figure 5: Structured interdisciplinary bedside rounds roles and process.

HEALTHINF 2017 - 10th International Conference on Health Informatics

366

Figure 6: Order menu customized for POKE-R awareness.

5 RESULTS

Our project is in production in the PICU at Loma

Linda University Children’s Hospital. To analyze the

success of the project, we compared patients prior to

the introduction of both POKE-R and SIBR to

patients after these programs were instituted. In all,

we analysed 3,338 pediatric ICU patients.

We have seen a reduction in POKE-R events by

8.7%. Specifically, this was a decrease of 1.8 POKE-

R events per patient per week. We compared this

patient cohort with a historical control set using

standard t-test methodology. This result was

statistically significant with p <0.012. Statistical

significance for our purpose is defined as p<0.05.

Furthermore, we saw significant reductions based

on event type. Medication administrations were

reduced by 1.2 administrations per patient per week.

Specimen collections were reduced by 0.3 pokes.

Radiology procedures and point of care tests were

also reduced. We saw an increase in line pokes, but

this was expected because inserting a line actually

reduces the pokes for medication administrations and

lab draws and therefore is not discouraged by the

program. Finally, we saw a reduction in surgeries but

we do not think this change was influenced by our

POKE-R program.

To determine the statistical significance of the

data we utilized t-tests and chi-square goodness of fit

All of our results met the criteria for statistical

significance except for painful poke counts and point-

of-care testing. Table 1 shows the means, deltas and

statistical significance from our analysis. The two

rows marked in red are not considered statistically

tests and one-way analysis of variance (ANOVA).

Poke-R - Using Analytics to Reduce Patient

367

significant due to p>0.05. Figure 7 shows the the one-

way analysis of variance (ANOVA) graph for all

pokes, where stage 1 is prior to implementing our

program and stage 2 is after program implantation.

The graph has green diamonds on it which describe

the 95% confidence intervals of the mean within the

upper and lower peaks of the diamond. The line

across the middle is the mean, and the width of the

diamond is proportional to the sample size. Figure 8

shows the control chart for all pokes.

We also analyzed specifically the asthma patients

and found a decrease in metabolic panels by 30% with

p<0.0001. For patients with hypo/hypernatremia, the

metabolic panel reduction was 16%. These results

demonstrate drops in Basic Metabolic Panels

performed during the post-implementation period.

Figure 9 shows the ANOVA graph for asthma and

cerebral salt wasting patients.

Table 1: Statistics for poke analysis.

Statistical

Variable

Mean

Pokes

/patient

week

ΔControl

Set

p(Prob>

|t|)

Allpokes 14.372‐1.76 0.003

Painful 2.638 +0.10 0.472

MAR 10.57‐1.19 0.007

Specimen 2.220‐0.306 .003

POCT 0.811 ‐0.190 .157

BMP

(Asthmaand

CSW)

1.741‐0.357 .000

Figure 7: ANOVA graph for all pokes.

Figure 8: Control chart for all pokes.

Figure 9: ANOVA graph for BMP for asthma and cerebral

salt wasting patients.

6 FUTURE WORK

We would like to do more data analysis and research

to quantify the benefits of the program including:

 Reduction in hospital-acquired infections

such as Central Line-associated

Bloodstream Infection (CLABSI)

 Reduction in cost

 Improved patient satisfaction

Additionally, patient satisfaction and cost

information are not currently in our data warehouse.

So, additional future work is to bring in these data

points. This will not only allow us to more accurately

monitor performance improvement, it will also enable

greater cost transparency to the provider, patient and

guarantor. We plan to integrate patient (and parent)

experience survey data to quantify improved

customer satisfaction and the cost benefits of our

results to the hospital, the guarantor and the payor.

Currently, the POKE-R evaluation process is

facilitated through printed and emailed reports even

though the data is in the Enterprise Data Warehouse.

HEALTHINF 2017 - 10th International Conference on Health Informatics

368

This is to eliminate the provider from having to access

multiple systems. We plan to have the POKE-R

details for a patient be directly linked to the patient’s

electronic health record. This way they can simply

view the needed POKE-R information when they are

already reviewing the patient’s chart.

Currently, we have the number of laboratory tests

but not the volume of specimen taken for the tests.

Another enhancement we want to make is to interface

with our laboratory system to get the precise volume

of blood collected. This will give us more accuracy

in measuring POKEs and associated risk for anemia.

We are also planning to roll out our POKE-R

analytics and process to more departments throughout

the hospital in the coming year.

7 CONCLUSION

We have implemented a comprehensive and

configurable analytics solution to give providers the

information they need to address excessive POKE-R

events in patients. While our project has only gone

into production in one hospital unit, we are already

seeing considerable evidence of improvement. This

project has the opportunity to reduce cost, improve

patient outcomes and increase customer satisfaction.

REFERENCES

Alharfi, I., Stewart T., Helali, I., Daoud, H., Fraser, D,

2014. Infection rates, fevers and associated factors in

pediatric severe traumatic brain injury. In Journal of

Neurotrauma.

Bateman, J., Lacroix, Boven, K., Forbes, P., Barton, et al,

2008. Anemia, Blood Loss, and Blood Transfusions in

North American Children in the Intensive Care Unit".

In American Journal of Respiratory and Critical Care

Medicine.

Salisbury, A.C., Reid, K.J., Alexander, K.P., Masoudi,

F.A., Lai, S.M., Chan, P.S., Bach, R.G., Wang, T.Y.,

Spertus, J.A. and Kosiborod, M., 2011. Diagnostic

blood loss from phlebotomy and hospital-acquired

anemia during acute myocardial infarction. Archives of

internal medicine, 171(18), pp.1646-1653.

Foster, C.B. and Sabella, C., 2011. Health care–associated

infections in children. JAMA, 305(14), pp.1480-1481.

CT Radiation in Kids: How Much of a Risk,

Really? Medscape. 2014.

Grissinger, M., 2011. Capping intravenous tubing and

disinfecting intravenous ports reduce risks of infection.

In Pharmacy and Therapeutics.

McVoy, M., Shandler, A, 2013. Anemia, Bleeding, and

Blood Transfusion in the Intensive Care Unit: Causes,

Risks, Costs, and New Strategies. In Am J Crit Care.

Ridout R., 2014. Prevent Pain and Organisms from sKin

and catheter Entry (POKE): Getting to the Why of Care

[Internet]. Harvard Business School Open Forum:

Dixie Regional Medical Center. Available from:

https://openforum.hbs.org/challenge/hbs-hms-health-

acceleration-challenge/innovations/prevent-pain-and-

organisms-from-skin-and-catheter-entry-poke-getting-

to-the-why-of-care.

Slovis, T., 2002. CT and Computed Radiography: The

Pictures Are Great, But Is the Radiation Dose Greater

Than Required?. In American Journal of

Roentgenology.

Brenner D., 2002. Estimating cancer risks from pediatric

CT: going from the qualitative to the quantitative. In

Pediatric Radiology.

Axt-Adam, P., van der Wouden, P., van der Does, E.,

1993. Influencing Behavior of Physicians Ordering

Laboratory Tests: A Literature Study. In Medical Care.

Sengupta, A., Lehmann, C., Diener-West, M., Perl, T.,

Milstone, A., 2010. Catheter Duration and Risk of

CLA-BSI in Neonates With PICCs. In Pediatrics.

Kelly, M., Conway, M., Wirth, K., Potter-Bynoe, G.,

Billett, A.L. and Sandora, T.J., 2011. Moving CLABSI

prevention beyond the intensive care unit: risk factors

in pediatric oncology patients. In Infection Control &

Hospital Epidemiology, 32(11), pp.1079-1085.

Sherwood, G., Adams-McNeill,

J., Starck, P., Nieto, B.,

Thompson, C.. 2000. Qualitative assessment of

hospitalized patients' satisfaction with pain

management. Research in Nursing Health.

Stein, J., Murphy, D., Payne, C., Clark, D., Bronstein, W.,

Tong, D., Castle, B., Shapiro, S, 2013. A Remedy for

Fragmented Hospital Care. In Harvard Business

Review.

Atchison, J., Wachendorfb, J., Haddockb, D., Mysiwb, S.,

Gribbleb, M., & Corriganb, J. 1993. Hyponatremia-

associated cognitive impairment in traumatic brain

injury. Brain Injury.

Algaze, C. et al., 2016. Use of a Checklist and Clinical

Decision Support Tool Reduces Laboratory Use and

Improves Cost. In Pediatrics.

Bae, J.. 2015. Value-based medicine: concepts and

application. In Epidemiology and Health..

Cooke, M., 2010, Cost Consciousness in Patient Care -

What Is Medical Education's Responsibility?. In New

England Journal of Medicine.

Porter, M., 2010. What Is Value in Health Care?. In New

England Journal of Medicine.

Weinberger, S., 2011. Providing High-Value, Cost-

Conscious Care: A Critical Seventh General

Competency for Physicians. In Annals of Internal

Medicine.

Schuh, S., Parkin, P., et al., 1989, High-Versus Low-Dose,

Frequently Administered, Nebulized Albuterol in

Children With Severe, Acute Asthma. In Pediatrics.

Brenner, D.J., 2010. Should we be concerned about the

rapid increase in CT usage?. Reviews on environmental

health, 25(1), pp.63-68.

Poke-R - Using Analytics to Reduce Patient

369