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Preventing Patient Harm One Patient At a Time

By Lynn McCain | July 31

According to the National Institutes of Health, approximately 400,000 hospitalized patients experience some form of preventable harm each year, up to and including death (more than 200,000 preventable deaths annually). At Michigan Medicine’s Department of Pathology, we understand that in many of these cases, Pathology has a role to play in partnering with clinicians to prevent harm to patients. However, the work involved to make the necessary operational changes with critical data insights is more than anyone could ask of our laboratory leaders, given the day-to-day demands of patient testing. This is where Pathology’s Division of Quality and Health Improvement (DQHI) can apply its resources and expertise to fill the gap. Staffed with three project managers, a data scientist, and a process improvement specialist, Dr. Jeffrey Myers, Vice Chair for Clinical Affairs and Quality, originally built this division to partner with our laboratory leadership to have this sort of impact on patient lives.

To illustrate this partnership in action, in the summer of 2022, Michigan Medicine nephrologist, Dr. Mike Heung, reached out to our DQHI team regarding concerns that he had with patients experiencing acute kidney injury (AKI) following cardiac surgery. Laboratory tests can identify patients at risk for AKI by testing for two key biomarkers, TIMP-2 and IGFBP-7, found in the patient’s urine. This non-invasive test, run on Pathology’s NephroCheck equipment, calculates a patient’s acute kidney injury risk score (AKIR), enabling intervention prior to the onset of severe kidney disease potentially leading to dialysis. However, clinicians were not routinely ordering this test for cardiac patients. Dr. Heung approached DQHI for ideas on how to increase utilization of this test.

Drs. Ric Valdez, Lee Schroeder, Carmen Gherasim and DQHI Staff Ross Smith and Keisha Beck team up with clinical colleagues, Drs. Milo Engoren, Mike Heung, and Robert Hawkins to address post-surgical acute kidney injury. DQHI management gave a green light to forming a project team, assigning Keisha Beck as project manager and Ross Smith as the data scientist. The team consulted with experts from across the spectrum of care as the project unfolded. These individuals included Dr. Mike Heung (Nephrology), Dr. Riccardo Valdez (Director of Clinical Pathology), Dr. Lee Schroeder (Associate Director of Clinical Pathology), Dr. Carmen Gherasim (Director, Toxicology and Chemistry Labs), Dr. Milo Engoren (Anesthesiology), and Dr. Robert Hawkins (Cardiac Surgery) to better understand AKI, workflows, and solutions that may work for both the clinicians and the patients. They went to the source and learned exactly who should take what action when to prevent possible AKI while adhering to best practice guidelines. Then the project team got busy crafting potential solutions.

After considerable consultation with the members of the multidisciplinary team, they developed a solution where surgeons would include AKIR testing in post-surgical order sets for specific patient profiles. In addition, Dr. Heung worked with the institution’s Health Information Technology & Services (HITS) team to build and activate two best-practice advisories (BPAs) that would appear when the AKIR results reached defined thresholds and the providing clinician attempted to place certain orders. If the result reached 0.3, the BPA would send an alert to the ordering clinician, recommending that they do not order certain drugs that are toxic to the kidneys, for example Lisinopril for high blood pressure, NSAIDS, or CT contrast media. In addition, other care recommendations included controlling blood sugar levels and monitoring of kidney function. If the result reached 2.0 or higher, the BPA provided an additional recommendation to the clinician that they refer the patient to the Nephrology service as they are at high risk for developing moderate to severe AKI.

For this to happen, however, the Department of Pathology had to re-activate the NephroCheck testing platform to process these tests. Dr. Carmen Gherasim also worked through regulatory requirements with her laboratory team to install and validate the equipment for accurate results.

Meanwhile, Ross Smith built a clinical dashboard that provides clinicians with a visualization to help them understand whether there were changes in the occurrence of AKI pre- vs post-intervention. This required him to integrate the data from both MiChart (Epic) and the Soft Laboratory Information System. To determine the effectiveness of the new protocols, Smith pulled historical data going back one year as well as prospective data over the ensuing year to aid Drs. Heung and Engoren in further developing guidelines and defining impact.

After reviewing the data, Dr. Heung and the project team determined the initial results were inconclusive and required a deeper dive into the data to better understand its implications. Dr. Heung is currently taking the lead on this deeper dive.

“It was a very positive experience working with my colleagues in Pathology,” stated Heung. “Right from the start, it was clear to me that we shared the same goals…having a positive impact on patient outcomes. As is sometimes the case, the data did not show us what we were expecting but we will learn more as we dig deeper.”

This project illustrates the power of collaborating across typically siloed channels within Michigan Medicine. Specialists from Nephrology, Cardiac Surgery, Anesthesiology, and Pathology came together for the good of their patients and developed an entirely new workflow designed to improve patient care and outcomes. While the final data interpretation is ongoing, the team remains committed to their goal of preventing harm to patients one patient at a time.

 
clinical pathology renal pathology dqhi clinical research patient safety
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