ABSTRACT 

ABSTRACT -Continuous Glucose Monitors (CGMs), which monitor interstitial glucose, currently are not FDA approved for inpatient use; however, CGMs have great potential to increase inpatient safety and improve both clinical outcomes and patient satisfaction.

Patients with subarachnoid hemorrhage (SAH) often develop hydrocephalus because of impaired cerebral spinal fluid (CSF) circulatory system. External ventricular drain (EVD) is widely used to drain CSF for SAH patients and monitor their intracranial pressure (ICP). While CSF circulation returns to normal in some patients, others develop chronic hydrocephalus (between 8.9% and 48% of patients) and require a permanent CSF shunt.

Abstract

Multiple sclerosis (MS) is a costly and progressive neurological disease that requires individualized monitoring. The rapid introduction of new disease-modifying therapies (DMTs) within the last several years accompanied by significant safety concerns following the introduction of new therapies has highlighted the need for a systematic tool to manage patient adherence, laboratory values, and adverse events throughout each step of the MS patient’s healthcare experience. The implementation of a registry dashboard tool to improve inefficiencies in resource allocation will promote patient safety, while resulting in cost-savings to the UCSF Medical Center. 

TEAM - Core implementation team members and titles

Michele M. Pelter, RN, PhD, Assistant Professor, Dir, ECG Monitoring Research Lab, Dept of Physiological Nursing

Xiao Hu, PhD, Associate Professor of Physiological Nursing and Neurosurgery, Affiliate Faculty of Institute for Computational Health Sciences, Core Member of UCB/UCSF Joint Bio-Engineering Graduate Program

David W Mortara, PhD, FACC, Associate Professor, UCSF School of Nursing

The opioid-abuse epidemic has led to a healthcare crisis costing an estimated $500 billion dollars in the US last year.  Seventy-five percent of patients that abuse prescription narcotics obtain them directly from their doctor or from friends and family that have prescriptions.  Physicians and surgeons have a responsibility and are under greater levels of scrutiny to restrict the amount of unnecessary narcotic medications they prescribe while ensuring appropriate pain control. Elective, outpatient surgeries are often a patient’s first exposure to opioids but can represent both a potential gateway for later abuse and a possible source of morbidity including constipation, nausea, and short- to medium- term addiction. There is tremendous variability in the pain tolerance of different patients making it difficult to appropriately prescribe narcotics for pain control. Despite this, most providers utilize a “one-size-fits-all” approach.  This results in narcotics being used unnecessarily when alternatives might suffice or in unused narcotics being shunted into the community, fueling abuse. The complications from opioid abuse, from constipation to overdose, is extremely costly to the healthcare system.  We propose piloting implementation of a simple, three-question, validated pre-operative pain assessment to help predict and direct the narcotic pain needs of patients undergoing elective, outpatient urologic surgeries. The project goal is to allow the prescriptions of narcotics to be tailored on a patient-by-patient basis and reduce the number of unnecessary narcotics prescribed by surgeons.  By assessing post-operative pain in patients with an inexpensive text-messaging service, we will avoid under-treatment of pain and avert trips to the emergency room. Eliminating narcotics will reduce costs to the hospital and US economy of opioid-related complications and consequences of abuse.

Initiative Owner(s): Keith Hansen, MD

Initiative Owner: Darryl Lau, MD

Executive Sponsor: Christopher P. Ames, MD, Adrienne Green, MD

ABSTRACT:

Recent evidence suggests that approximately 50% of patients with acute pulmonary embolism (PE) can be classified as low-risk and eligible for discharge from the Emergency Department (ED) without requiring inpatient care. Candidates for outpatient therapy can be identified as low risk using readily available validated scoring systems. The availability of direct oral anticoagulants, which are easier to administer than parenteral anticoagulants, has further facilitated the process of initiating anticoagulation outside of the hospital.

Highly effective and novel interventions for breaking the cycle of hospitalization for asthma and chronic obstructive lung disease are needed to minimize costs and disease burden.  Treatment of these two diseases accounts for a disportionate burden on UCSF Health's emergency rooms, intensive care units, and medical services.  Frequently, these hospitalizations could be prevented by better adherence to outpatient medications, earlier recognition and treatment of exacerbations, and smoking cessation.  Effective short term therapies for depression and stimulant craving have emerged, including ketamine assisted psychotherapy.  Ketamine is a dissociative anesthetic that primarily acts to block glutamate activation of the NMDA receptor; ketamine also antagonizes the nicotinic acetylcholine receptor. Due to its rapid and brief duration of action, and its lack of suppression of respiratory drive, ketamine is widely used for minor procedures in outpatient and emergency room settings. In 2017, the American Psychiatric Association published guidelines for use of low dose (sub-anesthetic) ketamine for treatment-resistant depression based on consistent evidence from small randomized clinical trials showing decreased suicidal ideation and increased mood. Combining ketamine with psychotherapy appears to prolong the beneficial effects of either intervention alone. Emerging information suggests that low-dose ketamine therapy can durably decrease craving for stimulants, including nicotine and cocaine, possibly by its effects on the insula and the interpeduncular nucleus. In this project, we propose a pilot project to use short course ketamine assisted psychotherapy among people with a history of recent hospitalization for asthma or COPD that was precipated, at least in part, by low adherence to outpatient medications or on-going use of inhaled stimulants.  To minimize costs, and to maximize the integration of ketamine treatment with psychotherapy oriented to pulmonary disease, we will perform this service during the day in an outpatient setting using a sleep study room that is used at night for family members of patients having sleep studies.  The service will include two preparatory visits, up to three sessions of ketamine assisted psychotherapy, and two subsequent sessions to integrate insights and reinforce changes in behavior.  Outcomes will include baseline and followup assessments for depression, anxiety (including anxiety reactions to trauma, such as near death experience from asthma), and substance use.  We will also conduct daily check-in's using redcap to track how ketamine sessions affect mood, pain, craving for nicotine (if applicable), and adherence to medications, positive airway pressure (PAP), and recognition of pulmonary symptoms.  All of these assessments will be performed in a highly cost effective manner using UCSF REDCAP, a HIPAA complaint survey and data management system.  We will use APEX to track health care utilization overall, hospitalization days, and ICU days.  The services will be provided by physicians or mid-level clinicians who have received specific training in ketamine-assisted psychotherapy, and several low cost programs are available.   Professional services will be billed to insurance whenever possible.  The budget will be used to cover the remaining unbilled cliniciain effort and to furnish the room.  By the end of the year, we will have data regarding hospitalization rates before and after the session which can be used to contract with payers for full payment for this extremely cost-effective service.