Effectiveness of Evidence-based Pneumonia CPOE Order Sets Measured by Health Outcomes

Impact of order set implementation on appropriate treatment of community-acquired pneumonia (CAP)

Objective

This study aimed to evaluate appropriate antimicrobial prescribing after implementing a pneumonia order set within a community teaching hospital.

Design

Retrospective chart review study.

Setting

450-bed community teaching hospital.

Participants

Patients who are 18 years of age or older admitted for treatment of community-acquired pneumonia (CAP) between October 1, 2021, and August 1, 2023.

Methods

This retrospective cohort study aimed to evaluate a composite endpoint of appropriate empiric antimicrobial selection, dosing, and duration in accordance with the national guidelines after the implementation of a CAP order set. Secondary outcomes included comparing hospital length of stay (LOS), readmission rates, mortality rates, and Clostridium difficile infection rates.

Results

A total of 236 patients were included (118 patients per group). Significantly more patients in the post-implementation group received guideline-concordant therapy for CAP (5.9% vs 35.6%, P < .001). Results were heavily influenced by improvements in appropriate durations of therapy (pre: 6.8% vs post: 39.9%, P < .001). There were no significant differences observed for LOS, 30-day readmission rates, C. difficile infections within 30 days, or mortality rates between groups. The order set was utilized in 66.1% of patients included in the post-implementation group.

Conclusions

Implementing an order set significantly improved inpatient antibiotic prescribing for CAP with no difference in clinical or safety outcomes. Antibiotic order sets will be a useful tool for antimicrobial stewardship program expansion into other common community-acquired infections.

Building on Antimicrobial Stewardship Programs Through Integration with Electronic Medical Records: The Australian Experience

Antimicrobial stewardship (AMS) is well established in Australian hospitals. Electronic medical record (EMR) implementation has lagged in Australia, with two Healthcare Information and Management Systems Society (HIMSS) Stage 6 hospitals and one Stage 7 hospital as of September 2020. Specific barriers faced by AMS teams with paper-based prescribing and medical records include real-time identification of antimicrobials orders; the ability to prospectively monitor antimicrobial use; and the integration of fundamental point of prescribing AMS principles into routine clinical practice. There are few local guidelines to assist Australian hospitals and AMS teams beyond “out of the box” EMR functionality. EMR implementation has enormous potential to positively impact AMS teams through more efficient workflows and the ability to expand the reach and coverage of AMS activities. There are inevitable limitations associated with EMR implementation that must be considered. In this paper, four Australian hospitals share their experience with EMR roll out, AMS customisation and how they have overcome specific barriers in local AMS practice.

[Information technology and eHealth to improve patient safety]

Patient safety is a key element of high-quality healthcare. Digitalization, new eHealth applications and data-based algorithms have high potential to make a significant contribution. This article presents current technological developments along a simplified patient journey from emergency medical triage, diagnosis and therapy to follow-up. The technical interventions are highly diverse and mostly accompanied by a low level of evidence, since most of them are from single academic projects or start-ups. Although there should be no doubt that technology is an important instrument for increasing patient safety, new technologies also involve new risks. Furthermore, technical measures must always be embedded in an overall concept of organizational measures, adequate education, training and accompanying research in order to generate the highest possible benefits and lowest possible risks.

The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit

BACKGROUND

Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited.

OBJECTIVE

The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes.

METHODS

A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set.

RESULTS

The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p < 0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury.

CONCLUSION

Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns.

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

Clinical Decision Support Tools and a Standardized Order Set Enhances Early Enteral Nutrition in Critically Ill Children

BACKGROUND

Critically ill children in a pediatric intensive care unit (PICU) have unique nutrition needs that are challenging to achieve and thus are at high risk of malnutrition. There is increasing evidence that children who reach caloric goals early have improved outcomes. The purpose of this initiative was to implement an enteral nutrition (EN) algorithm in a tertiary care PICU utilizing clinical decision support tools (CDSTs) and a standardized order set within an electronic health record.

METHODS

A quality improvement initiative was undertaken to implement an EN feeding protocol using electronic CDSTs, including a new standardized order set.

RESULTS

In a historical cohort of 376 patients, only 18% met goal EN in the first 48 hours of admission. The EN protocol was implemented in 272 patients who met 88% goal feed volume within 48 hours of intensive care unit admission. Median time to start EN (1.7 vs 1.3 days, P < 0.0001) and time to goal nutrition (2.8 vs 2.2 days, P < 0.001) improved after project implementation. Length of stay in the PICU was significantly reduced following protocol implementation (202 hours pre-implementation vs 156 hours post implementation, P < 0.0001).

CONCLUSIONS

We used CDSTs and standardized order sets to implement a nutrition algorithm to facilitate and likely improve the nutrition care of critically ill children.

Standardizing the Use of Albumin in Large Volume Paracentesis

Background

Albumin after large volume paracentesis (LVP) reduces paracentesis-induced circulatory dysfunction (PICD). The most efficacious dose of albumin for LVP is unclear.

Objective

To evaluate the impact of implementing a standardized LVP order set on albumin utilization and patient outcomes.

Methods

This is a retrospective review of patients with ascites due to cirrhosis who received a therapeutic paracentesis at a large, academic institution. Primary outcome was amount of albumin used prior to and after order set implementation. Albumin doses were standardized in the order set to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L). Patient outcomes were rates of hyponatremia, renal impairment, and hypotension.

Results

There were 100 patients included in each arm of the final analysis. Patients prior to order set implementation received a higher amount of albumin per liter removed compared to those post-implementation (8.3 g/L vs 6.5 g/L, respectively; P < .01). There were no significant differences between groups in absolute changes in serum sodium (0 mEq/L vs −1 mEq/L, P = .64), serum creatinine (0.06 mg/dL vs 0.05 mg/dL, P = .94), or systolic blood pressure (−4 mm Hg vs −3 mm Hg, P = .96). There were no differences between groups in rates of hyponatremia (1.6% vs 6.6%, P = .21), renal impairment (11.3% vs 11.5%, P = .97), or hypotension (17.4% vs 17.6%, P = .97).

Conclusions

Use of an order set to guide albumin dosing based on amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given with no difference in adverse effects.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.