Triage of Acute Decompensated Congestive Heart Failure in the Emergency Department
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1 Triage of Acute Decompensated Congestive Heart Failure in the Emergency Department Initial Results Using a Computer-Based Medical Decision-Support Tool Hisham M.F. Sherif, MD FACS FICS; Jason Nace, MD; Sharmila S. Johnson, RN MSN ACNS-BC CCRN, Angela DiSabatino, RN MSN; Desiree T. Hodges, RN MSN; Stephanie A. Klair, RN MSN ACNS-BC CCRN Departments of Cardiac Surgery, Emergency Medicine, Center for Cardiovascular Outcomes Research Christiana Hospital, Christiana Care Health System, Newark, Delaware
2 Disclosure Statement Ms. Debora J. Simmons, RN MSN CCRN CCNS recuses herself from the presentation due to conflict of interest All other co-investigators have no conflict of interest
3 Computer Applications in Medicine Medical Information Look-up Medical Imaging Filing and Data Storage
4 Computer Applications in Medicine Computer-aided diagnosis
5 The Automated Doctor Audio: Courtesy of comedian Ms Kristin Lindner. Performance at the Houston Improv Comedy Club, 2005
6 Challenges and Limitations of Computer-based Diagnosis Automated Medical Decision Making Systems The Shortfalls: - Inadequate - Imprecise - Non-Reproducible
7 Challenges and Limitations of Computer-based Diagnosis I. Non-Uniformity of System Elements: Variations of Human Patient Characteristics
8 II. Incomplete Understanding of the System s behavioral Patterns: Such as: 1. How diseases start and progress.
9 Research about the causes, course, behavior and modification of different diseases is still on-going. Our understanding of such processes and behavioral patterns remains incomplete.
10 2. The effects of different therapeutic modalities.
11 3. The effects of interaction between different System Elements and/or therapeutic modalities Population cohort factors Individual factors Compliance Socio-economic factors Historical evidence Prospective evidence Off-Label evidence Therapeutic variability Therapeutic/Medication interactions Side effects Complications Unexpected effects/idiosyncracies Co-existing conditions Unknown/Undiagnosed conditions
12 For example, rules and behavioral patterns in the Aviation Industry Systems have been well understood for over a century, = Feasible and easy to achieve optimal control over the system s components
13 4.Unpredictability of the Consequences or Results of Intended /Planned Actions: Unpredictability of the Effectiveness of Therapeutic Modality
14 5. The Diagnostic Software I.Q. A Computer Program will ALWAYS do what you TELL it to do, But rarely what you WANT it to do
15 Can We Teach the Computer? vs.
16 Basics of Medical Triage Quick Establishment of Diagnosis Assigning a Severity Score Establishing the Predicted Outcome Disposition (according to the predicted outcome)
17 Basics of Medical Diagnosis Information Gathering: Medical history Symptoms Physical Examination Laboratory Data Imaging Data Differential Diagnosis List Assignment of a Probability Hierarchy
18 Medical Triage Guess Who? (Diagnosis) Drop that knife! (Predicted Outcome) Book em, Danno! (Disposition)
19 Establishing a Diagnosis A -- Differential Diagnosis B-- Sorting out the Suspect List
20 1.The Possibilistic Approach a.k.a, DRAGNET
21 2. The Probabilistic Approach a.k.a.,what Are the Odds?! Bayes Theorem Bayesian Network
22 3. The Prognostic Approach a.k.a, Voted Most Likely to Succeed?
23 Computer-Based Diagnostic/Predictive Systems: Principles and Correlation Identify: - Problem - Objective H Sherif, S Sadeghi, G Mogel. Design and Construction of a Computer-Based Logical System for Medical Diagnosis. Stud Health Technol Inform 81 (2001), Published by IOS Press.
24 Our Tool HUGIN EXPERT A/S Gasværksvej 5 DK-9000 Aalborg DENMARK info at hugin dot com
25 Example Hisham M. Sherif, MD, et al. Design and Construction of a Computer-Based Logical System for Medical Diagnosis Studies in Health Technology and Informatics, vol. 81, 2001, James D. Westwood, et al, Editors.
26 Triage of Acute Decompensated Congestive Heart Failure Background: Congestive Heart Failure : About 2-4 million cases in the US 15 million cases worldwide. 550,000 new cases per year
27 Triage of Acute Decompensated Congestive Heart Failure Outcomes: -Congestive Heart Failure : 287,000 deaths per Year < 50% expected to live more than 5 years Class IV survival: At 1 Yr : 43% At 3 Yr : 18% M Gheorghiade and P Pang. Acute Heart Failure Syndromes. J Am Coll Cardiol : M Gheorghiade, F Zannad, G Sopko, et al. Acute Heart Failure Syndromes: Current State and Framework for Future Research. Circulation. 2005;112:
28 Triage of Acute Decompensated Congestive Heart Failure Cost: In-Patient care: 23.1 Billion $ 300% increase in readmission rates from (Patients >65 years) Readmission Cost up to 17.4 Billion $ per year (Medicare) Sources: The American Medical Association American Medical Directors Association Agency for Health Care Research and Quality
29 Some others work D Lombardo, T Bridgmean, N De Michelis, M Nunez. An academic medical centre s programme to develop clinical pathways to manage health care: Focus on acute decompensated heart failure. J Integrated Care Pathways. (2008);12:45-55 D Lee, P Austin, J Rouleau, P Liu, D Naimark, J Tu. Predicting mortality among patients hospitalized for heart failure. Derivation and validation of a clinical model. JAMA.2003;290: W Levy, D Mozaffarian, D Linker, S Sutradhar, S Anker, A Cropp, I Anand, A Maggioni, P Burton, M Sullivan, B Pitt, P Poole-Wilson, D Mann, and M Packer. The Seattle Heart Failure Model: Prediction of Survival in Heart Failure. Circulation. 2006;113:
30 Study Objective To develop a custom-built, computerbased clinical decision-support tool to: a) Help determine the underlying cause of the patient s clinical presentation b) Help the emergency department physician predict the likelihood of readmission for ADHF syndrome.
31 Acute Decompensated Congestive Heart Failure: Emergency Department Parameters Patient Factors: Age Gender Documented History of Congestive Heart Failure Prior Admission for Acute Decompensated CHF Symptomatology: Shortness of Breath Orthopnea/Paroxysmal Nocturnal Dyspnea Palpitations Chills Physical Examination: Heart Rate Systolic Blood Pressure Fever Presence of a Third Heart Sound Jugular Venous Distension Dependent Edema Laboratory Data: Serum Sodium Serum Creatinine White Blood Cell Count Serum Uric Acid Serum BNP Findings on Chest Radiograph: Unilateral Lung Infiltrates Bilateral Pleural Effusions
32 Acute Decompensated Congestive Heart Failure: The Predictive Program Basic Layout
33 Acute Decompensated Congestive Heart Failure: Diagnostic and Disposition Tiers
34 Acute Decompensated Congestive Heart Failure: The Predictive Program Run Mode
35 Initial Results Phase I: Proof-of-Concept -20 cases - Hypothetical, Randomly Generated Parameters
36 Initial Results Phase I: Successful Prediction: Diagnosis 17/20 (85%) Disposition 16/20 (80%) Phase I # of Patients Correct DX ID Accuracy Correct Dispo Correct DX Correct Dispo
37 Initial Results Phase II: Clinical-based, Real-World Retrospective Study Retrospective chart review Records-based parameters 100 Emergency Department case records Documented final diagnosis: 55 cases of Acute Decompensated Heart Failure 45 cases of Other Diagnoses
38 Initial Results Phase II: Case number by Diagnosis: ADHF 55 Stable HF 14 Pneumonia 8 COPD 7 Other 16 Total 100
39 Initial Results Phase II:
40 Initial Results Phase II:
41 Study Limitations Pilot study design Retrospective Chart Review Small Sample Size
42 Conclusion A Custom-built, Computer based predictive model, Using Evidence-based, population-wide real-life clinical data and trends can be a useful adjunct tool in clinical decision making
43 Conclusion...especially in high-paced, high risk clinical environments
44 THANK YOU!
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