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Sacramento, CA, United States

Sutter Health is a not-for-profit health system in Northern California, headquartered in Sacramento. It includes doctors, hospitals and other health care services in more than 100 Northern California cities and towns. Major service lines of Sutter Health-affiliated hospitals include cardiac care, women’s and children’s services, cancer care, orthopedics and advanced patient safety technology. Wikipedia.

Sox H.C.,Dartmouth Institute for Health Policy and Clinical Practice | Sox H.C.,Patient-Centered Outcomes Research Institute | Stewart W.F.,Sutter Health
Academic Medicine

In this issue, Farias and colleagues describe how to develop a clinical care pathway by using a structured, continuous learning process embedded within the day-to-day delivery of care. Their method is called Standardized Clinical Assessment and Management Plans (SCAMPs). A care pathway, such as a SCAMP, includes multiple decision points and related recommendations. The SCAMP process can test the validity of each decision point if clinicians document patient data and record their reasoning when they deviate from the recommended action at a decision point. The unique feature of SCAMPs is that they encourage dissent, unlike clinical practice guidelines (CPGs), algorithms, and bundled electronic health record protocols, which are designed to be followed. If a clinician deviates from the recommended action at a decision point, an explanation is required. This feedback, which should explain why a patient does not precisely "fit" the logic of the care pathway, may lead the SCAMP developers to modify the decision point.The authors of this Commentary argue that SCAMPs and CPGs, two approaches to developing clinical standards of care, are fundamentally equivalent. The key link between them is the recently described process of deconstructing a CPG into the many steps that are necessary to consistently apply it to clinical practice. The SCAMP process puts these steps to the test of daily practice.The Commentary ends with a list of foundational principles for developing standards of clinical care. These principles should apply to care pathways, algorithms, practice guidelines, or SCAMPs. Source

Rincon T.A.,Sutter Health
Telemedicine journal and e-health : the official journal of the American Telemedicine Association

This article evaluates the feasibility of a tele-intensive care unit (ICU) nurse-driven early identification and treatment process for severe sepsis patients in improving compliance to evidence-based practice. Florence Nightingale identified that by using science, logic, and compassion to manipulate the patient care environment nurses could create the best possible conditions for healing to occur. Nurses in a tele-ICU used this premise to initiate a standardized screening and data collection program using a custom-built document sharing application that conformed to the Surviving Sepsis Campaign (SSC) criteria for identification and treatment of severe sepsis. The tele-ICU nurses performed 89,921 screens on 36,353 ICU admissions to 161 ICU beds across a geographical range of 500 miles. Between January 1, 2006 and December 31, 2008, tele-ICU nurses identified 5,437 patients as meeting the criteria for severe sepsis. Statistically significant increases in compliance with SSC's bundled care recommendations were realized during this study period with four initial elements: antibiotic administration increased from 55% in 2006 to 74% in 2008 (p=0.001), serum lactate measurement increased from 50% to 66% (p=0.001), the initial fluid bolus of ≥ 20 mL/kg increased from 23% to 70% (p=0.001), and central line placement increased from 33% to 50% (p=0.001). A tele-ICU nurse-driven process can prompt earlier identification and improve compliance to evidence-based practice bundles for complex disease states such as severe sepsis. Source

Zarkhin V.,Stanford University | Sarwal M.M.,Sutter Health
Seminars in Immunology

Transplantation is the preferred therapy for the end stage organ disease. Since the introduction of organ transplantation into medical practice in 1953 [1], significant progress has been achieved in patient and graft survival rates due to improvements in surgical techniques and more targeted immunosuppressive medications [2]. Nevertheless, current gaps in the management of the transplant patient stem from an incomplete understanding about the heterogeneity of the injury response in organ transplantation, at different rates and different time points after transplantation, as well as our inability to monitor the immunologic threshold of risk versus safety in each individual patient. Recent advances in immunology/transplantation biology with the advent of high throughput " omic" assays such as gene microarrays, proteomics, metabolomics, antibiomics, chemical genomics and functional imaging with nanoparticles, offers us unique methods to interrogate and decipher the variability and unpredictability of the immune response in organ transplantation (Fig. 1) [3]. Recent studies using these applications [3-8] have uncovered a critical and pivotal role for specific B cell lineages in organ injury [9] and organ acceptance [10,11] (Fig. 2). The availability of specific therapies against some of these defined B cell populations provides for an exciting new field of B cell targeted manipulation that can both abrogate the allospecific injury response, as well as promote allospecific graft accommodation and health. © 2011 Elsevier Ltd. Source

Colonoscopy for colorectal cancer screening is the largest single source of income for gastroenterologists in the USA. Despite its proven value in preventing colon cancer, it is being scrutinized by payers and regulators as a high-volume procedure with variable quality, cost and documentation. In a rapidly evolving era of reimbursement for added value (high quality, affordable cost) rather than for individual transactions/volume, gastroenterologists are under pressure to change our practices to respond to the demands of the marketplace. Excellent guidance is available through our professional societies. © 2014, Springer Science+Business Media New York. Source

Faden R.,Johns Hopkins Berman Institute of Bioethics | Kass N.,Johns Hopkins Berman Institute of Bioethics | Stewart W.,Sutter Health | Tunis S.,Center for Medical Technology Policy
Medical Care

BACKGROUND: Electronic clinical data (ECD) will increasingly serve as an important source of information for comparative effectiveness research (CER). Although many retrospective studies have relied on ECD, new study designs propose using ECD for prospective CER. These designs have great potential but they also raise important ethics questions. AIMS: Drawing on an ethics framework for learning health care systems, we identify morally relevant features of prospective CER-ECD studies by examining 1 case of an observational study and a second of a pragmatic, randomized trial. We focus only on questions of consent and assume research has been subject to appropriate ethics review and oversight. RESULTS AND CONCLUSIONS: We conclude that a CER-ECD observational study that imposes no or minimal additional risk to or burden on patients may proceed ethically without express informed consent from participants in settings where: (a) patients are regularly informed of the health care institution's commitment to learning through the integration of research and practice; and (b) there are appropriate protections for patients' rights and interests. In addition, where (a) and (b) apply, some pragmatic, randomized trials that similarly impose no or minimal additional risk to or burden on patients may also proceed ethically without express consent, when certain additional conditions are satisfied, including: (c) the trial does not negatively affect patients' prospects for good clinical outcomes; (d) physicians have the option of using an intervention other than the one assigned if they believe doing so is important for a particular patient; and (e) the trial does not engage preferences or values that are meaningful to patients. Copyright © 2013 by Lippincott Williams & Wilkins. Source

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