Browsing by Author "Gallagher, David"

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Open Access
A full house: Re-shuffling our transfer strategy to better manage capacity across Duke Hospitals
(2016-03-01) Setji, Noppon; Gallagher, David; Rougeux, Matthew; Gerardo, Charles; Verma, Lalit; Sawyer, Suzanne; Odom, Nancia; Oliver, Joan; Demarco, Frank; Ross, Adia
See uploaded pdf version
Open Access
CUTTING OUR ‘LOS’SES: HOSPITALIST & EMERGENCY MEDICINE MULTIDISCIPLINARY PARTNERSHIP TO IMPROVE ED THROUGHPUT
(2015-04-01) Gallagher, David; Wachter, Adam; Setji, Noppon; Lamay, Edward; Burrows, Brian; Pickens, Andrew; Gerardo, Charles; Sawyer, Suzanne; Edwards, Faith; Babb, Mitch; Griffith, Brian; Verma, lalit
Open Access
Deployment of the Epic Readmission Risk Score in DUH GenMed Patients
(2019-03-01) Daley, Caitlin; Gallagher, David; Melton, Jessica; Long, Andrea; Goldstein, Benjamin; Brucker, Amanda; Kramer, Patricia; McCarthy, Colleen; Yanik, Jacquelyn
Open Access
Development of Emergency Department Case Management Case-Finding Tool
(2022-10-05) Gallagher, David; Bentley, Barbara; Barry, Ashley; Moulton, Marcia; Fracola, Amy; Dreibelbis, Lanie; Glenn, Adam; Flanagan, Katie
Society of Hospital Medicine – North Carolina Triangle Chapter Innovation Abstract Development of Emergency Department Case Management Case-Finding Tool David Gallagher1, Barbara Bentley2, Ashley Barry3, Marcia Moulton4, Amy Fracola5, Lanie Dreibelbis6, Adam Glenn6, Katie Flanagan2 1: Duke University Hospital Medicine Programs 2: Duke University Hospital Case Management 3: Duke Health Technology Solutions 4: Duke Regional Hospital Case Management 5: Duke Raleigh Hospital Case Management 6: Duke Health Performance Services Background: Case Managers (CM) are now a standard support component of emergency departments (ED) of large hospitals. They can help with improving quality and decreasing healthcare utilization and costs. ED CM help ensure hospital admissions from EDs are appropriate and if an alternative disposition for the patient exists, then they work towards that goal. ED CMs are important to decrease friction and barriers to the correct care for patients. ED CM responsibilities can include: • Utilization management roles such as evaluating the appropriateness of admission vs. observation vs. discharge • Arranging alternative care destinations such as skilled nursing facility or assisted living • Organizing outpatient resources such as meals, home health care, durable medical equipment • Scheduling medical care follow-up • Referring to support programs and social work for substance abuse, victims of violence, psychiatric care, etc. • Facilitating insurance coverage • Securing housing • Developing high utilizer or individual care plans • Counseling patients and families • Reviewing discharge instructions The majority of ED CM find patients they need to intervene on by using a manual process for case-finding which involves scanning multiple charts or relying on providers guiding them on who to see. The INTERMED tool for case finding is the most common tool in the literature but still represents a manual process that takes significant time. Purpose: As part of our work on reducing readmissions at Duke University Health System we hypothesized that the development of an automated tool for case finding would improve efficiencies for CM, allowing them more time for interventions such as readmission reduction strategies. Therefore, we developed an automated tool that stratifies patients in ED based on variables agreed to by our expert consensus opinion. Description: The tool resides in EPIC EMR ED track board in the CM tab. It is easily seen in CM standard views and workflows. We chose 11 different demographic and utilization variables and weighted them to create an overall CM Priority Score so that patients who should be seen by ED CM would score high. CM Priority scores were color-coded to indicate the need for CM support; red = high need, orange = medium, yellow = low, green = none. CM can hover their cursor over the score to discover the variables driving the score which may help with determining which interventions to apply. Four variables were scored high enough to ensure that CM always saw these patients: ED consult order for CM, potential readmission, complex care or behavioral concern flags, and hospice enrolled. Conclusions: The CM Priority Score tool went live 8/23/22 and we plan on assessing its efficacy and reporting out at a future time. We are holding a rapid improvement event to determine optimal interventions to pursue for patients with high scores in addressing patient needs, readmissions risk, ED utilization, and resource allocation.
Open Access
Development of Emergency Department Case Management Case-Finding Tool
(2023-03-27) Gallagher, David; Bentley, Barbara; Barry, Ashley; Moulton, Marcia; Fraccola, Amy; Santos, Rosimeire; Glenn, Adam; Howard, James; Kamath, Aparna; Flanagan, K
Background: Case Managers (CM) are now a standard presence in emergency departments (ED) of large hospitals, partnering with ED and Hospital Medicine providers to improve care. They are integral in improving hospital throughput and reducing unnecessary hospital admissions and readmissions. Case Managers generally identify high-risk patients using a manual chart review process or by provider request to determine whether hospital admissions are appropriate or if an alternative disposition for the patient exists. This manual case-finding process can be time-intensive and inefficient and was identified as an area of opportunity in rapid improvement events for ED CM at our institution. Purpose: As part of our work on reducing readmissions at an academic medical center our project aim was to develop an automated screening tool for case finding that would improve the ability of CM to identify patients at high risk for return to ED or hospitalization. This improvement in prediction could also be more efficient, allowing CM more time for interventions such as readmission reduction strategies. The Case Management Priority Score (CMPS) screening tool is a clinical innovation developed by interdisciplinary consensus opinion and we report our initial findings. Description: Before CMPS go-live, the standard case-finding methodology used by ED CM to identify high-risk patients was manual. High risk was defined as a return to ED or hospitalization within 7- and 30- day time frames of the index ED visit. Patients thought to be high risk by ED CM using manual case-finding were indicated by documentation in the medical record. The Case Management Priority Score resides in the electronic medical record (See Image 1: Figure) and went live on 9/1/2022. Eleven demographic and utilization variables were identified and weighted to determine an overall CMPS which would guide ED CM to which patients were at high risk for returns or hospitalizations. They can hover their cursor over CMPS to discover the variables impacting the score which may help determine which interventions to apply. Four variables were weighted high enough to ensure that CM always intervened; ED consult order for CM, prior ED or hospital utilization, complex care/behavioral flags, and hospice enrolled. Image 2 (Table) shows baseline characteristics for patients scoring high risk were different than the low risk in all areas except gender. The Table also shows that, compared to the prior manual case-finding methodology (8/2022), CMPS (9/2022) had a higher odds ratio of identifying patients that were at risk for most 7- and 30- day return to ED and hospitalization outcomes. The odds ratio for any 30-day return (ED or hospitalization) for CMPS in 9/2022 was 4.19 (3.17-5.53) vs 1.62 (1.28-2.07) for manual case-finding in 8/2022. Conclusions: In this clinical innovation project, the CMPS screening tool was found to be more predictive in identifying patients at risk for return to ED or hospitalization than manual case finding. If used by CM to identify ED patients to focus on, this may be more accurate than existing manual case-finding techniques, will help ED CM efficiencies, and help reduce returns to ED and hospitalizations. Our future focus for this work includes further analysis of the variables contributing to CMPS to refine the tool for prediction performance and develop strategies to increase its usage among CM.
Open Access
Discharge Summary Routing – Improvement by Automation
(2022-04-07) Gallagher, David; Anderson, Elizabeth; Knutsen, Kristian; Dreibelbis, Lanie; Walton, Barbara; Lovins, Jonathan; Telloni, Stephen; Shah, kevin
Open Access
Hospitalist satisfaction with an inpatient electronic progress note
(2010-12-10) Kurup, Vinod; Lineberger, Robert; Gallagher, David
Open Access
Impact of Geographic Cohorting on Length of Stay and Readmissions
(Journal of Hospital Medicine, 2023-03-29) Jolly Graham, Aubrey; Patel, Nilesh; Platt, Alyssa; Knutsen, Kristian; Capps, Vonda; Fletcher, Emily; Gallagher, David
Open Access
Implementation of a Hospital Medicine Morbidity and Mortality Conference and Mortality Review Using a Structured Mortality Instrument.
(2013-03-01) Bae, Jonathan; Acker, Yvonne; Govert, Joseph; Hester, Jason; Kachalia, Allen; Owens, Thomas; Snider, Wendy; Rohan, Shannon; Gallagher, David
Open Access
IMPLEMENTATION OF HOSPITAL BASED CLINICAL PERFORMANCE METRICS TEACHING SESSIONS FOR MEDICINE RESIDENTS ON DUKE GENERAL MEDICINE
(JOURNAL OF GENERAL INTERNAL MEDICINE, 2013-06-01) Gallagher, David; Setji, Noppon P; Bae, Jonathan
Open Access
Improving Length of Stay for General Medicine Inpatients through Standardized Multidisciplinary Rounds
(2022-03-25) Jolly-Graham, Aubrey; Capps, Vonda; Gallagher, David
Open Access
Is objective mobility data associated with pharmacologic venous thromboembolism (VTE) prophylaxis use among hospitalized older adults?
(Journal of Hospital Medicine, 2018-04-10) Pavon, Juliessa; Sloane, R; Pieper, Carl; Colon-Emeric, Cathleen; Gallagher, David; Cohen, Harvey; Hall, K; Morey, Miriam; McCarty, Midori; Ortel, Thomas; Hastings, Susan
Background: Clinical practice guidelines state that mobility is supposed to play an important role in determining use and duration of pharmacologic VTE prophylaxis. This study examines whether measured mobility levels relate to pharmacologic VTE prophylaxis use among hospitalized older adults. Methods: Prospective observational data from a sample of community-dwelling older adults aged ≥ 60 years, admitted to an academic hospital’s general medicine service. Inpatient mobility was objectively measured using ankle-mounted accelerometers from admission until discharge (or ≤ 7 days). Clinical and demographic factors, and pharmacologic VTE prophylaxis use was manually abstracted from the medical record. We performed descriptive statistics for daily mobility parameters (time spent in activity, sedentary time, and step counts) according to VTE risk stratification using a validated stratification tool (Padua Score) and prophylaxis use. Pearson’s correlation was used to determine the correlation of mobility measures with use and duration of VTE prophylaxis. Results: Among hospitalized older adults in this sample (N=65), 71% (n=46) were low risk for VTE occurrence, yet 62% (n=40) received pharmacological VTE prophylaxis during an average of 57% of their hospital stay (SD 46). Median time in activity was 65 minutes/day (IQR 40, 102; Range 5 – 289 mins/day). Median time spent in sedentary activity (awake but not moving) was 15 hrs/day (IQR 12, 17; Range: 3 – 20 hrs/day). Median total daily steps was 1370 (IQR 852, 2387; Range: 86 – 6134 steps/day). There was significantly greater sedentary time (16 hrs/day) for high risk patients compared to low risk patients (13 hrs/day) (p=0.02), but no differences in activity time or step counts. There were no detectable differences in mobility measures between those receiving and not receiving pharmacological VTE prophylaxis, and no significant correlations between mobility measures and duration of VTE prophylaxis. Conclusions: Among hospitalized older adults, use and duration of VTE prophylaxis did not differ by higher or lower mobility activity, suggesting that better mobility awareness is needed to guide appropriate pharmacological VTE prophylaxis use.
Open Access
Multi-source or “360” reviews in hospitalist performance appraisals
(2010-10-21) Gallagher, David
Multi-source or “360” reviews in hospitalist performance appraisals David Gallagher MD, Duke University, Durham, North Carolina Background: Physician performance appraisal programs are used to evaluate competence in important behaviors and skills. Multi-source or 360-degree surveys could be an effective and efficient method of assessing these competencies for hospitalists. Since 2006 we have used a multi-source feedback survey to evaluate hospitalists at Duke-Durham Regional Hospital (DRH). This feedback has been incorporated into the annual review for our hospitalists which also includes performance metrics in quality, productivity, patient satisfaction, and academics. With this year’s multi-source survey we have added questions on the satisfaction and usefulness of this tool. Although multi-source surveys have been tested in other physician specialties and in resident education, there are no definitive studies of it’s use with hospitalists. Methods: The multi-source survey used is web-based, confidential, and administered as part of the annual review process for DRH hospitalists. The survey is “multi-source” and sent to fellow hospitalists (physicians and non-physician providers), nurses, pharmacists, and care managers asking them to give feedback to the individual hospitalist (physician or non-physician provider) named for the survey. The survey uses questions with a Likert scale response (1-5) with comment fields. There are 16 questions which focus on medical knowledge, decision making, efficiency and management, documentation, responsiveness, communication skills, teamwork, dependability, and professionalism. This year we received IRB approval to add questions asking survey respondents and recipients about their satisfaction and perceived usefulness of this type of multi-source review. Results: The response rate for the 2010 multi-source feedback survey was 63% (133 surveys returned on 22 hospitalists; 211 surveys sent). Overall satisfaction with the survey was very high. Of all respondents, 99.2% answered “yes” that giving feedback to hospitalists through the survey was useful. Of hospitalists that were receiving the feedback, 97.3% found the feedback from the survey useful as part of their annual review process. 92.4 % of all respondents felt the survey asked the right questions. The comments also reflected high satisfaction levels with the survey instrument and process. Estimated time to administer this survey was 8 total staff hours (22 minutes per hospitalist reviewed). Conclusions: We have shown that a web-based multi-source feedback survey can be successfully used in a hospitalist program as part of the annual review process for hospitalists. This can be accomplished with high satisfaction from those participating in the review process with a reasonable time investment. Further refinement and validation of a multi-source survey tool for hospitalists is recommended given the unique nature of hospitalist work. Author disclosures: None
Open Access
Outcomes of a Structured Hospitalist Peer Mentoring Program
(2010-10-21) Gallagher, David; Woods-Powell, CT
Open Access
Patient Acuity Scores to Prevent Rapid Responses
(The Ochsner journal) O'Donnell, Christopher; Thomas, Samantha; Johnson, Crystal; Verma, Lalit; Bae, Jonathan; Gallagher, David
Background: In the last 10 years, patient safety committees nationwide have focused on creating taskforces such as rapid response teams (RRTs) that can intervene when patients start to decompensate prior to a code. At Duke Regional Hospital, approximately 50% of RRT activations were found to occur during the first 24 hours of a patient’s stay. Unlike critical care medicine, internal medicine does not have a widely accepted scale to grade the severity of illness. A scale was developed by Edelson et al in 2011 to quantify the likelihood of decompensation. The Duke hospitalists adapted this scale and used it prospectively to determine whether there was a correlation in the presenting acuity of illness and the number of RRT interventions in the first 24 hours and to see if there would be a decrease from year to year. Methods: A patient acuity score was adapted with permission, and patients were graded prospectively from admission. Patient data from June to December 2013 was summarized using N (%) for categorical variables and mean (standard deviation) for continuous variables. Patients transferred to resident service were excluded from the analysis, making the effective sample size 4,322 patients. The differences in mean severity score by occurrence of an RRT intervention in multiple categories were examined using analysis of variance. The total number of RRT interventions (at any time, within 12 hours, and within 24 hours) and unplanned transfers for June to December in 2012 and 2013 were compared using Wilcoxon rank sum tests for independent nonparametric samples. Additionally RRT interventions were grouped by score of 5 and above vs 4 and below and analyzed via chi square test. Results: From June to December 2013, there were a total of 4,577 encounters by the hospitalists. A total of 4,322 patients met inclusion criteria. Ninety-two percent of the patients had a recorded acuity score. An RRT intervention occurred in 113 patients. Mean acuity scores were compared between subgroups. There were significant differences in mean acuity scores between patients who experienced an RRT intervention at any time and those who did not, patients who experienced an RRT intervention within 12 hours of admission and those who did not, patients who experienced an RRT intervention within 24 hours of admission and those who did not, and patients who underwent an unplanned transfer and those who did not (all P<0.007). It is notable that 100% of the level 7 scores that had a rapid response were transferred to the critical care unit, as well as 79% of the level 6 scores. There were no significant differences in the number of rapid responses between 2012 and 2013. Patients were then analyzed via chi square test in grouped distribution of scores of ‡5 and <5. Significant differences were seen in the total number of RRT interventions, the number of unplanned transfers and the number of RRTs within 24 hours. However, when looking at the grouping among patients with only RRT intervention, there was no significant difference between groups with a score ‡5 and those 4. Conclusion: A patient acuity scale to quantify how likely a patient is to have an adverse event has been shown to correlate with rapid responses and transfers to a higher level of care within the first 24 hours. Patients who had an RRT intervention had a higher score overall with a trend toward increasing transfer rates with elevated scores. Using this scoring system did not lead to a lower amount of rapid responses in comparing years; however, it could be used for selective monitoring to prevent sentinel events.
Open Access
Poor Adherence to Risk Stratification Guidelines Results in Overuse of Venous Thromboembolism Prophylaxis in Hospitalized Older Adults.
(Journal of hospital medicine, 2018-06) Pavon, Juliessa M; Sloane, Richard J; Pieper, Carl F; Colón-Emeric, Cathleen S; Cohen, Harvey J; Gallagher, David; Morey, Miriam C; McCarty, Midori; Ortel, Thomas L; Hastings, Susan N
Open Access
Residents Finding Their Roots: Resident Workshops to Improve Patient Safety on the Wards while Teaching Residents Root Cause Analysis
(2014-04-01) Boole, Lindsay; Seidelman, Jessica; Zaas, Aimee; Cheely, George; Chudgar, Saumil; Clarke, Jeffrey; Gallagher, David; Jolly Graham, Aubrey; O'Brien, Cara; Setji, Noppon; Shah, Bimal; Thomas, Samantha; Bae, Jonathan
Open Access
Targeted Improvements in Follow-up Phone Calls as a Strategy to Improve Readmission Rates.
(2018-03-22) Daley, Caitlin; Gallagher, David; Spell, Rhonda; Preston, Karen; Bowen, Emily; Kramer, Pat
Open Access
Transferring general medicine patients from Duke Hospital to Durham Regional Hospital to address hospital bed capacity
(2010-12-10) Gallagher, David
Transferring general medicine patients from Duke Hospital to Durham Regional Hospital to address hospital bed capacity David Gallagher MD, Duke University Background: Hospital and emergency department overcrowding can affect the quality and safety of care delivered to patients. As one solution to overcrowding and patient throughput, hospitalists at Duke University Hospital (DUH) developed an inter-facility “reverse” transfer process where stable general medicine patients who met predetermined criteria could be directly admitted from the Duke ED to the affiliated Duke community hospital - Durham Regional Hospital (DRH). Methods: Since 2009, patients who presented to DUH ED were screened for appropriateness of inter-facility transfer and admission to DRH. Criteria for patient selection and a transfer process were developed. If a patient met criteria for transfer and agreed to the transfer they were directly admitted to DRH medicine units from the Duke ED. DUH Hospitalists did all of the admission work in the Duke ED using DRH systems; computerized physician order entry, medication reconciliation, and dictation systems. The patient’s were transferred by ambulance. The physician admitting work was done entirely by the “sending” hospitalist at Duke. We received IRB approval to get demographic and clinical data of our initial experience with this direct admission process. Results: Prior to August 2010 we have transferred 44 patients using this protocol. Demographics of patients transferred: average age 58.7 years, 54.5 % female, 45.5% male, 54.5% white, 38.6% black, 6.8% asian or hispanic. Length of stay for these patients was 3.9 days (CMA LOS 3.57 days), Case Mix Index 1.09, Readmission within 30 days 13.6%, 79.5% discharged to home (21.5% to other facilities), 2 patients died in their hospitalization after transfer to DRH (4.5% in-hospital mortality). Review of the deaths showed these deaths were not unexpected . The primary patient diagnoses were representative of general internal medicine. Conclusions: Interfacility transfer and direct admission of stable general medicine patients from a tertiary academic emergency department to a community hospital can help with hospital bed capacity. With a structured protocol in place the outcomes of the patients admitted in this fashion are similar to the standard admission processes.
Open Access
University of California San Francisco Lab Medicine Resident Critical Reviews - Disseminated Histoplasmosis and the Urinary Histoplasmosis Antigen
(University of California San Francisco Lab Medicine Resident Critical Reviews, 1992-06-01) Gallagher, David
Review article written for University of California San Francisco Laboratory Medicine "Critical reviews" in June 1992 by Dr David Gallagher. Covers background of disseminated histoplasmosis and diagnostic approach. Critical review of the urinary histoplasmosis antigen test available at the time.