TargetPath

Implementing an evidence-based guideline for management of hyperglycemic emergencies

Opportunity

Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when a patient's body produces high levels of blood acids called ketones.   

When we started this work, there were approximately 200-300 annual admissions for DKA at the Hospital of the University of Pennsylvania (HUP). An analysis of the emergency department (ED) treatment pathway for DKA showed seven guidelines in use and no consensus around appropriate treatment. Long-held conventions dictated for care to be delivered in the intensive care unit (ICU) despite research showing that level of care to be unnecessary for DKA.

Intervention

TargetPath is a comprehensive program designed to translate evidence-based guidelines into action at the bedside.  

Patients at risk for DKA are identified using a dashboard that monitors admissions into the ED and ED providers are prompted via secure text message with just-in-time evidence-based protocols to take action when patients fulfill care criteria.  

The clinician-designed protocol is designed to be actionable and easy to use so that multidisciplinary care teams can provide efficient and high-value care to patients with DKA consistently. At the time of transfer from the ED, huddles with pharmacists ensure the safe transfer of care.

Impact

By decreasing care variations and appropriately triaging patients based on the level of care required, TargetPath enables more patients to go directly home from ED, freeing up ICU beds for sicker patients. 

During the initial pilot at HUP, TargetPath led to savings of half a day of length of stay for all DKA patients and cut ICU utilization in half. Following the pilot, supporting order sets were built into the electronic health record to guide workflows and further reinforce the pathway. 

TargetPath is the standard of care for patients at risk for DKA at HUP. The team's insights and approach to refining and optimizing evidence-based guidelines serve as a roadmap for other clinical teams working to implement standardized care delivery.

Phase 2: It does work
Collaborators

Ilona Lorincz, MD
Nikhil Mull, MD
Cassie Bellamy, PharmD
Angela Mills, MD
Clinton Orloski, MD
Stephanie Maillie, MSN, RN, CCRN, CCNS
Marybeth O'Malley, MSN, RN, ACNS-B
Joyce Finnegan, BSN, RN, CEN

Innovation leads

Katherine Choi, MD
Roy Rosin, MBA
Shivan Mehta, MD, MBA, MSHP

Platforms
Funding

Innovation Accelerator Program

Innovation Methods

Fake front end
Piloting a fake front end involves putting a simulated version of a product into the hands of intended users - one that doesn't yet actually perform the intended function - so that you can observe if and how it will be used in context.
 
A fake front end will help you answer the question, "What will people do with this?"
 
The first successful mobile device was created by an innovator who carried a block of wood around in his pocket to see when and why he pulled it out to pretend using it, revealing both what to build and how to build it.
Fake front end

The team collected feedback from providers as they utilized multiple paper iterations of the pathway, which led to more specific inclusion criteria and user-friendly design.

Mini-pilot
High fidelity learning can come from low fidelity deployment.
 
Mini-pilots will allow you to learn by doing, usually by deploying a fake back end. You might try a new intervention with ten patients over two days in one clinic, using manual processes for what might ultimately be automated.
 
Running a "pop-up" novel clinic or offering a different path to a handful of patients will enable you to learn what works and what doesn't more quickly. And, limiting the scope can help you gain buy-in from stakeholders to get your solution out into the world with users and test safely.
Mini-pilot

We piloted a targeted intervention unit in the ED where resources could be pulled in as needed to test our assumption that DKA patients could be effectively cared for outside of the ICU. The temporary unit was staffed with floor nurses, on-call ICU nurses, and a range of other resources.

In just the first case, the team identified unnecessary resources such as the ICU-level nurse and validated a safe care approach for non-ICU floors.

Videos

Pitch Day 2017