Christiana Care Value Institute

Who We Are

The Value Institute at Christiana Care is a diverse team of experts collaborating in the discovery and delivery of value-centered knowledge to improve health.

Who We Serve

To develop, deliver and evaluate innovative solutions impacting population health, patient experience, system performance and policy development.

How We Work

The Value Institute leads the way in conducting real-world research on today’s most pressing health care issues, helping to deliver better health, better care and better value for our neighbors.

Publications

Outcomes with advanced versus basic life support in blunt trauma
Outcomes with advanced versus basic life support in blunt trauma
Farrell MS, Emery B, Caplan R, Getchell J, Cipolle M, Bradley KM

Am. J. Surg. 2020 Jan;

PMID: 32000980

Abstract

INTRODUCTION: The role of advanced life support (ALS) versus basic life support (BLS) in blunt trauma is controversial. Previous studies have shown no mortality benefit with ALS for penetrating trauma but the blunt population has mostly remained unaddressed.
METHODS: A retrospective cohort study was conducted at a Level 1 trauma center comparing outcomes in blunt trauma patients managed by ALS versus BLS from July 1, 2014 to December 31, 2014. Both Injury Severity Score (ISS) and select Abbreviated Injury Score (AIS) were used to determine differences in mortality, length of stay (LOS) and complications based on mode of transportation, prehospital time, and number of prehospital interventions.
RESULTS: 698 total patients were identified. Mortality and complications were grossly higher in ALS patients (p = 0.01 and < 0.001, respectively). When accounting for ISS and AIS there was no difference in mortality (p=<0.001-0.003). Prehospital interventions did not increase prehospital time (p = 0.7) but did correlate with increased mortality (p < 0.001).
CONCLUSION: There is no mortality advantage for blunt trauma patients managed by ALS versus BLS.
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Health Care Hotspotting - A Randomized, Controlled Trial
Health Care Hotspotting - A Randomized, Controlled Trial
Finkelstein A, Zhou A, Taubman S, Doyle J

N. Engl. J. Med. 2020 01;382(2):152-162

PMID: 31914242

Abstract

BACKGROUND: There is widespread interest in programs aiming to reduce spending and improve health care quality among "superutilizers," patients with very high use of health care services. The "hotspotting" program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services.
METHODS: We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition's care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge.
RESULTS: The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group.
CONCLUSIONS: In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition's program than among those who received usual care. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).
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Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance
Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance
Whyte C, Alhasani H, Caplan R, Tully AP

Clin Neurol Neurosurg 2019 Dec;190:105641

PMID: 31869626

Abstract

BACKGROUND/OBJECTIVE: Systemic prophylactic antibiotics have been used to reduce the rate of neurosurgical drain-related infections (DRIs) but the optimal duration is unknown. The Neurocritical Care Society Consensus Statement for External Ventricular Drain (EVD) management recommends a single antibiotic dose preoperatively. Data regarding antibiotic management for other neurosurgical drains (e.g. subgaleal and subdural drains) are lacking. Previously at our institution antibiotics were continued for the duration of drain placement. In 2016 an EVD bundle was implemented to standardize nursing care, and antibiotic duration was changed to one preoperative dose for all neurosurgical drains. The objective of this study was to compare the incidence of DRI, non-DRI, and antibiotic resistance before and after the implementation of an EVD bundle and limited duration antibiotics.
PATIENTS AND METHODS: This was a single center, quasi-experimental study that included patients status post EVD or craniotomy/craniectomy with subgaleal or subdural drain placement. The pre-intervention period was June 2014 through May 2015 and the post-intervention period was January 2017 through December 2017.
RESULTS: Ninety-one patients were included in the pre-intervention group and 54 in the post-intervention group. The use of limited duration antibiotics (< 48 h) was 14.3 % in the pre-intervention group and 96.3 % in the post-intervention group (p < 0.001). Five DRIs were identified in the pre-intervention group and 3 in the post-intervention group (5.5 % vs 5.6 %, p = 1.00). Of patients who developed a non-DRI, 77.5 % had a resistant non-DRI in the pre-intervention group compared to 48 % in the post-intervention group (p = 0.01). The rates of resistant DRI (80 % vs 66.7 %, p = 1.00) andClostridium difficile infection (1.1 % vs 3.7 %, p = 0.56) were similar between groups.
CONCLUSIONS: Implementation of an EVD bundle and limited duration antibiotics reduced antibiotic exposure with no associated increase in risk of DRI. Rates of resistant non-DRI were significantly lower in the post-intervention group.
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