VigiLanz Supports Innovative New Approach at Cincinnati Children’s Hospital
Nephrotoxic medications are critical for many patients. Unfortunately, they can also sometimes lead to acute-kidney injury in pediatric patients. To address this problem, Cincinnati Children’s Hospital Medical Center created a complex algorithm to identify patients at risk. The program has led to a 40 percent reduction in AKIs.
VigiLanz supports the program by monitoring patient datawith a complex set of exposure criteria and alerting providers in near real-time if a patient has been exposed to nephrotoxins. It also lets providers know if injury occurs.
The following is an excerpt from Pharmacy Practice News. For more information about the collaboration between VigiLanz and Cincinnati Children’s to reduce AKI, please read our press release and learn more about the solution that is functional and customizable for any hospital, regardless of EMR platform.
Dubbed NINJA, or Nephrotoxic Injury Negated by Just-in-time Action, a new solution enables real-time identification and monitoring of pediatric patients at risk for acute kidney injury (AKI) from exposure to nephrotoxic drugs.
So far, the program appears to be putting a significant dent in the problem—a greater than 40% reduction in AKI, which the authors contend has reached epidemic proportions in the nation’s hospitals.
Nephrotoxic medication exposure is one of the most common causes of AKI in children. “We know that children need nephrotoxins. These are lifesaving medications,” said Stuart L. Goldstein, MD, the director of the Center for Acute Care Nephrology at Cincinnati Children’s Hospital Medical Center and primary developer of NINJA. “But children should only get the nephrotoxic medications they need for the duration they need them.
Clinical surveillance can help healthcare systems more quickly identify clinical care problems, such as those related to medication errors and poor usage of antibiotics. But it can also help healthcare systems prevent problems from occurring in the first place.
That’s according to Bart Abban, PhD, director of analytics and data science at VigiLanz, who spoke about predictive analytics and clinical surveillance at the recent HIMSS Conference in Orlando.
“We’ve fully integrated a machine-learning platform into our real-time system,” said Abban, during his presentation. “We can look forward [at potential events], look in real time, and look back at historical data. It’s a fully closed-loop.”
Firm foundation needed
Much of the foundation of predictive analytics, Abban noted, comes from creating rules and alerts based on historical data. “You need a data repository,” he said. “We have vast amount of rich data, years and years of data.”
Health systems have many predictive analytics solutions to choose from. But Abban said VigiLanz stands apart because it provides a broader spectrum of alerts and customizations related to all types of patient care problems.
“With our platform you can do readmissions today, tomorrow you can start looking at mortality risk, you can look at adverse events, glycemic control,” he said. “We are currently developing a model on C. diff to alert clinicians to patients who are at high risk of getting C. diff. The sky is the limit.”
Abban shared three examples of how VigiLanz is providing predictive analytics to health systems:
Since many hospitalized patients have symptoms that resemble sepsis, it can be difficult for providers to identify sepsis cases or identify patients who are most at risk. VigiLanz created a rules engine so that hospitals can use certain criterion—such as vital signs, labs, microbiology, comorbidities, and medications—to identify patients at risk. VigiLanz can then alert providers when patients are at risk, and providers can monitor these patients more closely and treat them proactively. Since data is updated in near real time, providers always have access to the most up-to-date information related to patients at risk.
Acute kidney injury
Certain medications are essential for patients, but they can also lead to acute-kidney injury. The conventional approach is to monitor patients via labs, however, that means providers can only intervene after injury has already occurred. VigiLanz created a series of risk factors that can help providers more closely monitor patients, and proactively adjust medications as needed.
Risk factors include:
High risk nephrotoxic medications
Other drugs administered
Age, race, chronic morbidities, ICU stay or surgery
VigiLanz created a rules-based engine to help health systems monitor the likelihood of a cluster or outbreak of hospital-acquired infections.. VigiLanz created alerts based on algorithms for various types of infections, and health systems are able to configure their own alert thresholds depending on their needs, areas of concern, and priorities.
Health systems using the VigiLanz platform to improve patient care and prevent patient care problems can rest assured that critical alerts won’t be missed by providers, said Abban. He noted that VigiLanz can track whether providers are taking actions related to the alerts they receive. If not, alerts can be reissued or the health system can follow up with providers directly. “It’s a whole ecosystem where you can extract the value of predictive analytics,” he said.
MINNEAPOLIS & CINCINNATI – (November 29, 2018) – VigiLanz and Cincinnati Children’s Hospital Medical Center today announced a collaboration that leverages Cincinnati Children’s ground-breaking research on pediatric nephrotoxic kidney injury and VigiLanz’s capabilities to commercialize a solution for Acute Kidney Injury (AKI) in pediatric patients. Dubbed NINJA, or Nephrotoxic Injury Negated by Just-in-time Action, the solution enables real-time identification and monitoring of patients at risk for AKI due to exposure to nephrotoxic drugs.
“Pediatric acute kidney injury is a serious problem that traditionally could not be identified in real-time, which impacted our ability to identify the patients who most needed treatment,” stated Dr. Stuart L. Goldstein, MD, FAAP, FNKF, Director of the Center for Acute Care Nephrology and primary researcher on NINJA. “By partnering with VigiLanz, Cincinnati Children’s is applying our unprecedented research to a commercially-available solution that accurately characterizes pediatric AKI epidemiology, reducing AKI and improving patient outcomes.”
Commercially available to hospitals and health systems focused on mitigating pediatric AKI, NINJA automates a time-consuming manual screening process that includes evaluating patients for exposure to 57 nephrotoxic medications, imaging contrast dye, and recent renal testing. For medications, manual screening is limited to the last 24 hours, while the contrast dye evaluation requires reviewing records for the previous seven days to determine if it was received by the patient.
Leveraging NINJA algorithms built into VigiLanz rules, an AKI monitoring dashboard lists all patients that meet the NINJA exposure criteria as well as the criteria that put the patient in the at-risk category. These criteria include medication exposure, serum creatinine data, and patient history of AKI. When patients meet at-risk criteria, they are placed on the monitoring list in real time, where they remain until 48 hours after their risk has passed.
The platform also features metric outputs that can be customized with respect to service lines and time periods, while robust reporting tools provide the ability to trend conditions over time via automated run charts. It also enables automatic and customizable data extraction for all metric elements, including inpatient census by location or service line.
“By expanding awareness of the extensive research conducted by Cincinnati Children’s, this partnership will help drive improvements in pediatric AKI outcomes,” said VigiLanz Chairman and CEO Dr. David Goldsteen, MD, MBA. “Those improvements can be realized quickly, too, as the NINJA dashboard is not just a concept but rather a tangible solution now available to any hospital interested in limiting AKI associated with nephrotoxic drugs.”
Founded in 2001, VigiLanz Corporation (www.vigilanzcorp.com) is a privately held, rapidly growing provider of SaaS health care intelligence and predictive analytics. The firm is focused on aggregating disparate EHR transactional workflow and documentation data across health systems to identify real-time clinical issues that avoid or minimize harm, optimize clinical outcomes and support preventive care along the entire health system continuum. VigiLanz supports a large and growing community of hospital CMOs, CMIOs, CIOs, quality teams, infectious disease and control specialists, pharmacists, and other clinicians dedicated to real-time inpatient and outpatient care. VigiLanz is shaping the emerging era of real-time health care by delivering enterprise intelligence technology and services that improve clinical outcomes, patient care and operational effectiveness.
Ranked by U.S. News & World Report as one of the nation’s best children’s hospitals, the 629-bed Cincinnati Children’s Hospital Medical Center is a leading medical research institution and teaching hospital caring for children from across the globe. Established in 1883, the healthcare system’s 15,260 employees engage in 1.25 million patient encounters each year, including approximately 34,000 admissions and 103,000 emergency department visits.
Cincinnati Children’s comprises the Department of Pediatrics of the University of Cincinnati College of Medicine, offering comprehensive clinical services ranging from treatments for rare and complex conditions to well-child care. It is the third-highest recipient of research grants from the National Institutes of Health among pediatric institutions and is among just 7% of hospitals in the U.S. to have earned Magnet-designation (2013-2017) by the American Nurses Credentialing Center.
CINCINNATI CHILDREN’S WAS DETERMINED TO DECREASE PROLONGED USE OF VANCOMYCIN
With a growing body of evidence associating acute kidney injury (AKI) with an increased risk for development of chronic kidney disease, end-stage renal disease and mortality, Cincinnati Children’s was determined to reduce rates of AKI among its pediatric inpatient population. Baseline data indicated that, on average, six inpatients each week developed AKI during or within a week of discontinuing a vancomycin course. Additional evidence also suggested that extended courses of vancomycin—which when used beyond four days for empiric courses creates potentially unnecessary exposure to a nephrotoxic medication—may have been unintended.
Thus, vancomycin utilization was a natural target as the healthcare system embarked upon its mission to reduce the risk of AKI in pediatric patients. Specifically, Cincinnati Children’s sought to:
Decrease episodes of acute kidney injury associated with vancomycin use.
Decrease vancomycin exposure.
Decrease prolonged courses of vancomycin.
Increase oversight and approval for prolonged vancomycin exposure.
Success would require a close partnership between pharmacists and physicians that would enable implementation of an innovative, multistep quality improvement program focused on reducing the risk of vancomycin-induced kidney injury in pediatric patients. It also necessitated implementation of surveillance, clinical decision support and reporting technology capable of triggering interventions and educating clinicians on best practices.
Integrated within an existing antimicrobial stewardship program (ASP) and AKI reduction efforts, a core team of pharmacists, physicians, the chief medical resident and a quality improvement expert identified key drivers and implemented interventions including standardized orders, improved medical record documentation and integration of new processes into normal workflow. This enabled a stepwise approach using “plan-do-study-act” cycles.
Cincinnati Children’s also deployed the VigiLanz ASP solution to automate key processes, including screening and monitoring patients. The cloud-based platform leverages data collected from Cincinnati Children’s electronic medical record, physician order entry, laboratory and pathology systems to monitor patients in real-time for drug interactions and ineffective or inappropriate antibiotics. When potential issues are identified, alerts are triggered to enable clinical pharmacists and other members of the care team to take appropriate action.
Leveraging VigiLanz helped Cincinnati Children’s to create a sustainable and scalable framework that guides appropriate and safe use of antimicrobials while also promoting the safe and effective use of other medications. By enabling the provision of enterprise-wide guidance on the use of vancomycin in a matter of minutes each day, the technology helped drive significant improvements. These included:
Decreasing AKI associated with vancomycin exposure to an average of 4 per week from a baseline average of 6 per week, with sustained efforts likely to prevent an estimated 100 cases of vancomycin-associated acute kidney injury per year.
Decreasing vancomycin exposure (days of therapy/1000 patient days) by 43%, putting Cincinnati Children’s below the 25th percentile from a baseline near the 50th percentile.
Decreasing instances of prolonged courses of vancomycin by 44% hospital-wide.
Increasing ASP/ID approval in courses of vancomycin greater than four days to an average of 95% from a baseline average of 53%.
Cincinnati Children’s efforts to reduce AKI were recognized by the Association of Health-System Pharmacists, which gave the health system its 2016 Award for Excellence in Medication Safety.
“…We believe we can decrease the potential downside by choosing antibiotics that are likely to be just as effective but have less risk of increasing antibiotic resistance,” said David Haslam, M.D., an infectious disease specialist who joined Cincinnati Children’s specifically to launch its ASP initiative. “…Some hospitals just say ‘you can’t use that drug.’ Our approach will be ‘you might want to consider [another drug].’ We hope physicians will view this as bringing a lot of potential benefit.”– Silva, Mary. “Finding the Balance.” Research Horizons. Winter 2014.