Optimization of Patient Treatment

CPR: Cardiac Pathway Reasoning

From a clinical perspective and together with our colleagues at the Cardiac Surgery Department of the Johns Hopkins University and Hospital, we are interested in finding the causal factors for major clinical inefficiencies that are associated with the highest degrees of mortality and morbidity.

Heparin Induced Thrombocytopenia (HIT):

Heparin is the standard anticoagulant drug used for cardiopulmonary bypass patients. About 5% of the patients receiving heprain develop heparin induced thrombocytopenia (HIT), a condition that can lead to thrombosis (38-76% increased risk), severe bleeding, stroke, amputation, acute renal failure, respiratory failure, and sudden death (20-30% increase in early mortality). Identifying patients at higher risk and their individual response to medications would allow early prediction and treatment of HIT before its onset. 

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Bounce backs:

Defined as a patient discharged from the intensive care unit readmitted back to that intensive care unit prior to discharge, bounce backs are associated with a high mortality rate as well as a large increase in hospital costs. Identifying which patients are at highest risk for bounce back and allowing us to target resources designed specifically for that population should be able to decrease bounce backs and improve the quality and efficiency of our care.

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Predicting Acute Kidney Failure:

Renal failure after open heart surgery is the most morbid of all of morbidities routinely captured in the evaluation of the quality of a cardiac surgical program. In fact, the development of acute renal failure is associated with 30% to 50% of mortalities. Evidence has shown that both intra and immediate postoperative behavior affects the incidence of renal failure. By better understanding those variables that play a role in renal failure, we may be better able to decrease its incidence.

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Assessing Causes of Prolonged Intubation:

This morbidity is the second most morbid of complications associated with cardiac surgery. Mechanical ventilation greater than 24 hours, for example, increases risk of pneumonia and postoperative infections by a factor of 15 compared to less than 12 hours. Understanding the causes of prolonged intubation by determining the variables associated with it, and perhaps causing its occurrence, could allow targeting of those variables and could have a tremendous impact on postoperative morbidity in cardiac surgery.

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Assessing Inefficiencies in Blood Transfusions:

Cardiac surgery accounts for 20% of the transfusions in the United States. However, evidence-based practice is lacking for the majority of these transfusions, as witnessed by the institutional rates for transfusion, they vary between 10% and 90% for different patients. By better understanding the variables associated with transfusions, as well as looking at outcomes associated with transfusions, we may be better able to manage this precious resource and use it in a more evidence-based manner.

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Hospital readmission rates, are increasingly being viewed as a quality measure. Clearly, readmissions are expensive, and perhaps avoidable. Identifying a population of patients at high-risk for readmission utilizing a robust database to best define them would allow us to target therapy and apply resources designed specifically for that group of patients. Most importantly, characterizing the high risk patient accurately would allow us to better utilize scarce resources by allowing us to focus efforts where it matters.

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