Todd L Allen

Intermountain Medical Center, Salt Lake City, Utah, United States

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Publications (35)78.54 Total impact

  • Society for Academic Emergency Medicine 2015; 05/2015
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    ABSTRACT: Despite evidence that guideline adherence improves clinical outcomes, management of pneumonia patients varies in emergency departments (EDs). We study the effect of a real-time, ED, electronic clinical decision support tool that provides clinicians with guideline-recommended decision support for diagnosis, severity assessment, disposition, and antibiotic selection. This was a prospective, controlled, quasi-experimental trial in 7 Intermountain Healthcare hospital EDs in Utah's urban corridor. We studied adults with International Classification of Diseases, Ninth Revision codes and radiographic evidence for pneumonia during 2 periods: baseline (December 2009 through November 2010) and post-tool deployment (December 2011 through November 2012). The tool was deployed at 4 intervention EDs in May 2011, leaving 3 as usual care controls. We compared 30-day, all-cause mortality adjusted for illness severity, using a mixed-effect, logistic regression model. The study population comprised 4,758 ED pneumonia patients; 14% had health care-associated pneumonia. Median age was 58 years, 53% were female patients, and 59% were admitted to the hospital. Physicians applied the tool for 62.6% of intervention ED study patients. There was no difference overall in severity-adjusted mortality between intervention and usual care EDs post-tool deployment (odds ratio [OR]=0.69; 95% confidence interval [CI] 0.41 to 1.16). Post hoc analysis showed that patients with community-acquired pneumonia experienced significantly lower mortality (OR=0.53; 95% CI 0.28 to 0.99), whereas mortality was unchanged among patients with health care-associated pneumonia (OR=1.12; 95% CI 0.45 to 2.8). Patient disposition from the ED postdeployment adhered more to tool recommendations. This study demonstrates the feasibility and potential benefit of real-time electronic clinical decision support for ED pneumonia patients. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    Annals of Emergency Medicine 02/2015; DOI:10.1016/j.annemergmed.2015.02.003 · 4.33 Impact Factor
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    ABSTRACT: Rationale: Severe sepsis and septic shock are leading causes of intensive care unit (ICU) admission, morbidity, and mortality. The effect of compliance with sepsis management guidelines on outcomes is unclear. Objectives: To assess the effect on mortality of compliance with a severe sepsis / septic shock management bundle Methods: Observational study of a severe sepsis / septic shock bundle as part of a quality improvement project in eighteen ICUs in eleven hospitals in Utah and Idaho Measurements and Main Results: Among 4329 adult subjects with severe sepsis or septic shock admitted to study ICUs from the emergency department between January 2004 and December 2010, hospital mortality was 12.1%, declining from 21.2% in 2004 to 8.7% in 2010. All-or-none total bundle compliance increased from 4.9% to 73.4% simultaneously. Mortality declined from 21.7% in 2004 to 9.7% in 2010 among subjects not compliant with one or more bundle element. Regression models adjusting for age, severity of illness, and comorbidities identified an association between mortality and compliance with each of inotropes and/or red cell transfusions, glucocorticoids, and lung protective ventilation. Compliance with early resuscitation elements during the first 3 hours following emergency department admission caused ineligibility, through lower subsequent severity of illness, for these later bundle elements. Conclusion: Total severe sepsis and septic shock bundle compliances increased substantially and were associated with a marked reduction in hospital mortality after adjustment for age, severity of illness, and comorbidities in a multicenter ICU cohort. Early resuscitation bundle element compliance predicted ineligibility for subsequent bundle elements.
    American Journal of Respiratory and Critical Care Medicine 07/2013; 188(1-1):77-82. DOI:10.1164/rccm.201212-2199OC · 11.99 Impact Factor
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    ABSTRACT: BACKGROUND: Computed tomography (CT) pulmonary angiography use has increased dramatically, raising concerns for patient safety. Adherence to recommendations and guidelines may protect patients. We measured adherence to the recommendations of Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED II) investigators for evaluation of suspected pulmonary embolism and the rate of potential false-positive pulmonary embolism diagnoses when recommendations of PIOPED II investigators were not followed. METHODS: We used a structured record review to identify 3500 consecutive CT pulmonary angiograms performed to investigate suspected pulmonary embolism in 2 urban emergency departments, calculating the revised Geneva score (RGS) to classify patients as "pulmonary embolism unlikely" (RGS≤10) or "pulmonary embolism likely" (RGS>10). CT pulmonary angiograms were concordant with PIOPED II investigator recommendations if pulmonary embolism was likely or pulmonary embolism was unlikely and a highly sensitive D-dimer test result was positive. We independently reviewed 482 CT pulmonary angiograms to measure the rate of potential false-positive pulmonary embolism diagnoses. RESULTS: A total of 1592 of 3500 CT pulmonary angiograms (45.5%) followed the recommendations of PIOPED II investigators. The remaining 1908 CT pulmonary angiograms were performed on patients with an RGS≤10 without a D-dimer test (n=1588) or after a negative D-dimer test result (n=320). The overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses of pulmonary embolism occurred in 2 of 3 patients with an RGS≤10 and a negative D-dimer test result. CONCLUSIONS: Nonadherence to recommendations for CT pulmonary angiography is common and exposes patients to increased risks, including potential false-positive diagnoses of pulmonary embolism.
    The American journal of medicine 11/2012; 126(1). DOI:10.1016/j.amjmed.2012.05.028 · 5.30 Impact Factor
  • American Thoracic Society 2012 International Conference, May 18-23, 2012 • San Francisco, California; 05/2012
  • American Thoracic Society 2012 International Conference, May 18-23, 2012 • San Francisco, California; 05/2012
  • American Thoracic Society 2012 International Conference, May 18-23, 2012 • San Francisco, California; 05/2012
  • Am J Respir Crit Care Med; 01/2012
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    ABSTRACT: PURPOSE CT pulmonary angiography (CTPA) is frequently used for diagnosis of suspected pulmonary embolism (PE). The rate of false positive and false negative studies increases when the pretest probability for PE is discordant with the results of this test. We measured rates of inaccurate diagnosis of suspected PE for CTPA as interpreted by general vs. chest radiologists and stratified the results by pretest probability. METHOD AND MATERIALS This retrospective study was conducted in the Emergency Departments at Intermountain Medical Center and LDS Hospital in Salt Lake City, Utah. All CTPAs from July 1, 2009 to April 30, 2010 were identified through a query of the Intermountain Enterprise Data Warehouse. Studies originally interpreted by the general radiology group were blindly re-interpreted by one of three fellowship-trained chest radiologists. The chest radiologists’ interpretations were used as the standard to measure the rates of false-positive and false-negative diagnosis. Kappa coefficients for agreement amongst the chest radiologists were calculated by overlapping 20% of the sample. Pretest probability was calculated for each patient using a Revised Geneva Score (RGS). The patients were stratified based on pretest probability and the rates of inaccurate diagnoses were reported for each group. RESULTS 241 consecutive positive studies and 241 randomly selected negative studies were distributed to the study radiologists and 99 studies overlapped with two study radiologists. Thirteen/298 studies (4.4%) were false-positive and 7/283 studies (2.5%) were false-negative. The chest radiologists’ Kappa coefficients were 1.0, 0.94, and 0.94. The pretest probabilities of the study sample by RGS were low probability 25%, intermediate probability 64%, and high probability 11%. False positive rates for low, intermediate, and high probability were 3.1%, 5.3%, and 0%. False negative rates for the same groups were 6.0%, 2.2%, and 0% respectively. CONCLUSION CTPA carries risk for inaccurate diagnosis. Our results showed that this risk of inaccuracy varied according to the pre-test probability for PE. CLINICAL RELEVANCE/APPLICATION The rates of inaccurate diagnosis of pulmonary embolism with CT pulmonary angiography vary with pre-test probability for disease. A pre-test probability assessment is recommended prior to imaging.
    Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 12/2011
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    ABSTRACT: We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.
    Annals of emergency medicine 09/2011; 59(1):35-41. DOI:10.1016/j.annemergmed.2011.07.032 · 4.33 Impact Factor
  • American Thoracic Society 2011 International Conference, May 13-18, 2011 • Denver Colorado; 05/2011
  • American Thoracic Society 2010 International Conference, May 14-19, 2010 • New Orleans; 05/2010
  • American Thoracic Society 2010 International Conference, May 14-19, 2010 • New Orleans; 05/2010
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    ABSTRACT: We apply a previously described tool to forecast emergency department (ED) crowding at multiple institutions and assess its generalizability for predicting the near-future waiting count, occupancy level, and boarding count. The ForecastED tool was validated with historical data from 5 institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n=52,560) at 4 sites and 10 months (n=44,064) at the fifth. Three outcome measures-the waiting count, occupancy level, and boarding count-were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared with observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured with the median absolute error. The tool was successfully used for 5 different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at 4 of 5 sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the median absolute error of the waiting count ranged between 0.6 and 3.1 patients, the median absolute error of the occupancy level ranged between 9.0% and 14.5% of beds, and the median absolute error of the boarding count ranged between 0.9 and 2.8 patients. The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at 5 external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems.
    Annals of emergency medicine 09/2009; 54(4):514-522.e19. DOI:10.1016/j.annemergmed.2009.06.006 · 4.33 Impact Factor
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    ABSTRACT: Objectives. To determine whether the skill performance and psychomotor agility, as measured by the endotracheal intubation success rate, of air ambulance medical personnel would be affected by the potential fatigue incurred when increasing the length of their shifts from 12 to 24 hours. Methods. This was a retrospective review of all flight and intubation records from a large air medical transport system from 1997, when 24-hour shifts were in place, and six months (March–August) of 1996, during which 12-hour shifts were scheduled. Records of all intubation efforts during both periods, including multiple attempts per patient, and outcomes of all attempts, were recorded. Results of successes and failures were tabulated for both ultimate intubation outcome per patient and all attempts per patient for each calendar day and for the 12 hours between 19:00 and 07:00 when fatigue might play a role. Results from the two study periods were compared using Fisher's exact test. Results. During the six months of 1996, 190 of 199 (95.5%) patients were ultimately successfully intubated. These patients required 237 attempts (80.1% successful). During 1997, 362 of 376 (96.3%) patients were successfully intubated, and required 438 attempts (82.6% successful). There was no statistically significant difference in the number of ultimately successful intubations (p = 0.66) or total intubation attempts (p = 0.37) between 1996 and 1997. Analysis of intubations between 19:00 and 07:00 revealed 81 of 84 (96.4%) patients successfully intubated in 1996, with 81 of 103 (78.6%) attempts successful. During 1997, 173 of 180 (96.1%) patients were ultimately successfully intubated, with 173 of 212 (81.6%) attempts successful. Again, there was no significant difference in the number of successful intubations (p = 0.99) or intubation attempts (p = 0.55) between 1996 and 1997. Conclusion. Psychomotor agility of air ambulance medical personnel, as measured by the success rate of endotracheal intubation, was not affected by the potential additional fatigue incurred as a result of increasing shift length from 12 to 24 hours.
    Prehospital Emergency Care 07/2009; 5(4):340-343. DOI:10.1080/10903120190939481 · 1.81 Impact Factor
  • Annals of Emergency Medicine 10/2008; 52(4). DOI:10.1016/j.annemergmed.2008.06.163 · 4.33 Impact Factor
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    ABSTRACT: The goals of this investigation were to study the temporal relationships between the demands for key resources in the emergency department (ED) and the inpatient hospital, and to develop multivariate forecasting models. Hourly data were collected from three diverse hospitals for the year 2006. Descriptive analysis and model fitting were carried out using graphical and multivariate time series methods. Multivariate models were compared to a univariate benchmark model in terms of their ability to provide out-of-sample forecasts of ED census and the demands for diagnostic resources. Descriptive analyses revealed little temporal interaction between the demand for inpatient resources and the demand for ED resources at the facilities considered. Multivariate models provided more accurate forecasts of ED census and of the demands for diagnostic resources. Our results suggest that multivariate time series models can be used to reliably forecast ED patient census; however, forecasts of the demands for diagnostic resources were not sufficiently reliable to be useful in the clinical setting.
    Journal of Biomedical Informatics 06/2008; 42(1):123-39. DOI:10.1016/j.jbi.2008.05.003 · 2.48 Impact Factor
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    Kelly A Larrabee · Mark H Stevens · Todd L Allen
    JAAPA: official journal of the American Academy of Physician Assistants 08/2007; 20(7):27-8. DOI:10.1097/01720610-200707000-00006
  • Shari J Welch · Spencer S Jones · Todd Allen
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    ABSTRACT: Intermountain Healthcare (Salt Lake City), in conjunction with emergency department (ED) staff at LDS Hospital, designed an integrated patient tracking system (PTS) and a specialized data repository (ED Data Mart) that was part of an overall enterprisewide data warehouse. After two years of internal beta testing the PTS and its associated data captures, an analysis of various ED operations by time of day was undertaken. Real-time data, concurrent with individual ED patient encounters from July 1, 2004 through June 30, 2005 were included in a retrospective analysis. A number of patterns were revealed that provide a starting point for understanding ED processes and flow. In particular, ED census, acuity, operations, and throughput vary with the time of day. For example, patients seen during low-census times, in the middle of the night, appear to have a higher acuity. Radiology and laboratory utilization were highly correlated with ED arrivals, and the higher the acuity, the greater the utilization. Although it is unclear whether or not these patterns will be applicable to other hospitals in and out of the cohort of tertiary care hospitals, ED cycle data can help all facilities anticipate the resources needed and the services required for efficient patient flow. For example, the fact that scheduling of most service departments falls off after 5:00 P.M., just when the ED is most in need of those services, illustrates a fundamental mismatch between service capacity and demand.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 06/2007; 33(5):247-55.
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    ABSTRACT: Emergency department (ED) overcrowding has become a frequent topic of investigation. Despite a significant body of research, there is no standard definition or measurement of ED crowding. Four quantitative scales for ED crowding have been proposed in the literature: the Real-time Emergency Analysis of Demand Indicators (READI), the Emergency Department Work Index (EDWIN), the National Emergency Department Overcrowding Study (NEDOCS) scale, and the Emergency Department Crowding Scale (EDCS). These four scales have yet to be independently evaluated and compared. The goals of this study were to formally compare four existing quantitative ED crowding scales by measuring their ability to detect instances of perceived ED crowding and to determine whether any of these scales provide a generalizable solution for measuring ED crowding. Data were collected at two-hour intervals over 135 consecutive sampling instances. Physician and nurse agreement was assessed using weighted kappa statistics. The crowding scales were compared via correlation statistics and their ability to predict perceived instances of ED crowding. Sensitivity, specificity, and positive predictive values were calculated at site-specific cut points and at the recommended thresholds. All four of the crowding scales were significantly correlated, but their predictive abilities varied widely. NEDOCS had the highest area under the receiver operating characteristic curve (AROC) (0.92), while EDCS had the lowest (0.64). The recommended thresholds for the crowding scales were rarely exceeded; therefore, the scales were adjusted to site-specific cut points. At a site-specific cut point of 37.19, NEDOCS had the highest sensitivity (0.81), specificity (0.87), and positive predictive value (0.62). At the study site, the suggested thresholds of the published crowding scales did not agree with providers' perceptions of ED crowding. Even after adjusting the scales to site-specific thresholds, a relatively low prevalence of ED crowding resulted in unacceptably low positive predictive values for each scale. These results indicate that these crowding scales lack scalability and do not perform as designed in EDs where crowding is not the norm. However, two of the crowding scales, EDWIN and NEDOCS, and one of the READI subscales, bed ratio, yielded good predictive power (AROC >0.80) of perceived ED crowding, suggesting that they could be used effectively after a period of site-specific calibration at EDs where crowding is a frequent occurrence.
    Academic Emergency Medicine 11/2006; 13(11):1204-11. DOI:10.1197/j.aem.2006.05.021 · 2.20 Impact Factor

Publication Stats

334 Citations
78.54 Total Impact Points

Institutions

  • 2008–2012
    • Intermountain Medical Center
      Salt Lake City, Utah, United States
  • 2011
    • University of Utah
      • Division of Emergency Medicine
      Salt Lake City, Utah, United States
  • 2009
    • University of Pittsburgh
      • Department of Emergency Medicine
      Pittsburgh, Pennsylvania, United States
  • 2002–2007
    • Salt Lake City Community College
      Salt Lake City, Utah, United States
  • 2006
    • St. Mary Medical Center
      Long Beach, California, United States