Evaluation of a Clinical Decision Support System and an Automated Electronic Health Record Alert on Outpatient Prescribing of Cefdinir

Acute bacterial upper respiratory infections are common indications for antibiotics in pediatrics, and many prescriptions may be inappropriate. Novel approaches to outpatient antimicrobial stewardship interventions are needed. This quasi-experimental study of an order set and best practice advisory alert targeting cefdinir prescriptions demonstrated an 8.4% decrease in cefdinir prescribing (P ≤ .001).

Implementation of a Gastrografin Order Set for Small Bowel Obstruction Across a Health System: A Cohort Study

BACKGROUND

The use of Gastrografin (GG) in the management of adhesive small bowel obstruction (SBO) has been shown to decrease the length of stay and operative intervention.

METHODS

This retrospective cohort study examined patients with an SBO diagnosis prior to implementation (PRE, January 2017-January 2019) and following implementation (POST, January 2019-May 2021) of a GG challenge order set made available across 9 hospitals within a health care system. Primary outcomes were utilization of the order set across facilities and over time. Secondary outcomes included time to surgery for operative patients, rate of surgery, nonoperative length of stay, and 30-day readmission. Standard descriptive, univariate, and multivariable regression analyses were performed.

RESULTS

PRE cohort had 1746 patients and POST had 1889. The utilization of GG increased from 14% to 49.5% following implementation. Significant variability existed within the hospital system with utilization at each individual hospital from 11.5% to 60%. There was an increase in surgical intervention (13.9% vs 16.4%, P = .04) and decrease in nonoperative LOS (65.6 vs 59.9 hours, P < .001) following implementation. For POST patients, multivariable linear regression showed significant reduction in nonoperative length of stay (-23.1 hours, P < .001) but no significant difference in time to surgery (-19.6 hours, P = .08).

DISCUSSION

The availability of a standardized order set for SBO can result in increased Gastrografin administration across hospital settings. The implementation of a Gastrografin order set was associated with decreased length of stay in nonoperative patients.

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

The Surviving Sepsis Campaign recommends standard operating procedures for patients with sepsis. Real-world evidence about sepsis order set implementation is limited.

OBJECTIVES

To estimate the effect of sepsis order set usage on hospital mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis.

MAIN OUTCOMES AND MEASURES

Hospital mortality.

RESULTS

The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68-221] vs 179 [98-379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0-15.0] vs 7.6 [2.5-21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8-9.0] vs 6.0 [3.2-12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66-0.73).

CONCLUSIONS AND RELEVANCE

In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

Comparing Adherence with Best Practices in End-of-Life Care After Implementing the End-of-Life Order Set: A Quality Improvement Project in an Ottawa Academic Hospital

Background

Physicians in acute care require tools to assist them in transitioning patients from a "life prolonging" approach to "end-of-life care," and standardized order sets can be a useful strategy. The end-of-life order set (EOLOS) was developed and implemented in the medical wards of a community academic hospital.

Objective

To compare adherence with best practices in end-of-life care after implementing the EOLOS.

Methods

We conducted a retrospective chart review of admitted patients with expected deaths in the year preceding EOLOS implementation ("before EOLOS" group), and in the 12 to 24 months following EOLOS implementation ("after EOLOS" group).

Results

A total of 295 charts were included: 139 (47%) in the "before EOLOS" group and 156 (53%) in the "after EOLOS" group, of which 117/156 charts (75%) had a completed EOLOS. The "after EOLOS" group demonstrated more "do not resuscitate" orders and more written communication to team members about comfort goals of care. There was a decrease in nonbeneficial interventions in the last 24 hours of life in the "after EOLOS" group: high-flow oxygen, intravenous antibiotics, and deep vein thrombosis/venous thromboembolism prophylaxis. The "after EOLOS" group demonstrated increased prescription of all common end-of-life medications, except for opioids, which had a high preexisting rate of prescription. Patients in the "after EOLOS" group showed a higher rate of spiritual care and palliative care consult team consultation.

Conclusion

Findings support standardized order sets as a good framework allowing generalist hospital staff to improve adherence to established palliative care principles and improve end-of-life care of hospital inpatients.

Usability and Utility of Human Immunodeficiency Virus Pre-exposure Prophylaxis Clinical Decision Support to Increase Knowledge and Pre-exposure Prophylaxis Initiations among Pediatric Providers

OBJECTIVES

 An effective clinical decision support system (CDSS) may address the current provider training barrier to offering preexposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV) infection. This study evaluated change in provider knowledge and the likelihood to initiate PrEP after exposure to a PrEP CDSS. A secondary objective explored perceived provider utility of the CDSS and suggestions for improving CDSS effectiveness.

METHODS

 This was a prospective study using survey responses from a convenience sample of pediatric providers who launched the interruptive PrEP CDSS when ordering an HIV test. McNemar's test evaluated change in provider PrEP knowledge and likelihood to initiate PrEP. Qualitative responses on CDSS utility and suggested improvements were analyzed using framework analysis and were connected to quantitative analysis elements using the merge approach.

RESULTS

 Of the 73 invited providers, 43 had available outcome data and were included in the analysis. Prior to using the CDSS, 86% of participants had never been prescribed PrEP. Compared to before CDSS exposure, there were significant increases in the proportion of providers who were knowledgeable about PrEP (p = 0.0001), likely to prescribe PrEP (p < 0.0001) and likely to refer their patient for PrEP (p < 0.0001). Suggestions for improving the CDSS included alternative "triggers" for the CDSS earlier in visit workflows, having a noninterruptive CDSS, additional provider educational materials, access to patient-facing PrEP materials, and additional CDSS support for adolescent confidentiality and navigating financial implications of PrEP.

CONCLUSION

 Our findings suggest that an interruptive PrEP CDSS attached to HIV test orders can be an effective tool to increase knowledge and likelihood to initiate PrEP among pediatric providers. Continual improvement of the PrEP CDSS based on provider feedback is required to optimize usability, effectiveness, and adoption. A highly usable PrEP CDSS may be a powerful tool to close the gap in youth PrEP access and uptake.

Effectiveness of a Diabetes-Focused Electronic Discharge Order Set and Postdischarge Nursing Support Among Poorly Controlled Hospitalized Patients: Randomized Controlled Trial

BACKGROUND

Although the use of electronic order sets has become standard practice for inpatient diabetes management, there is limited decision support at discharge.

OBJECTIVE

In this study, we assessed whether an electronic discharge order set (DOS) plus nurse follow-up calls improve discharge orders and postdischarge outcomes among hospitalized patients with type 2 diabetes mellitus.

METHODS

This was a randomized, open-label, single center study that compared an electronic DOS and nurse phone calls to enhanced standard care (ESC) in hospitalized insulin-requiring patients with type 2 diabetes mellitus. The primary outcome was change in glycated hemoglobin (HbA_1c) level at 24 weeks after discharge. The secondary outcomes included the completeness and accuracy of discharge prescriptions related to diabetes.

RESULTS

This study was stopped early because of feasibility concerns related to the long-term follow-up. However, 158 participants were enrolled (DOS: n=82; ESC: n=76), of whom 155 had discharge data. The DOS group had a greater frequency of prescriptions for bolus insulin (78% vs 44%; P=.01), needles or syringes (95% vs 63%; P=.03), and glucometers (86% vs 36%; P<.001). The clarity of the orders was similar. HbA_1c data were available for 54 participants in each arm at 12 weeks and for 44 and 45 participants in the DOS and ESC arms, respectively, at 24 weeks. The unadjusted difference in change in HbA_1c level (DOS - ESC) was -0.6% (SD 0.4%; P=.18) at 12 weeks and -1.1% (SD 0.4%; P=.01) at 24 weeks. The adjusted difference in change in HbA_1c level was -0.5% (SD 0.4%; P=.20) at 12 weeks and -0.7% (SD 0.4%; P=.09) at 24 weeks. The achievement of the individualized HbA_1c target was greater in the DOS group at 12 weeks but not at 24 weeks.

CONCLUSIONS

An intervention that included a DOS plus a postdischarge nurse phone call resulted in more complete discharge prescriptions. The assessment of postdischarge outcomes was limited, owing to the loss of the long-term follow-up, but it suggested a possible benefit in glucose control.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03455985; https://clinicaltrials.gov/ct2/show/NCT03455985.

Pediatric Provider Utilization of a Clinical Decision Support Alert and Association with HIV Pre-exposure Prophylaxis Prescription Rates

OBJECTIVES

An electronic clinical decision support (CDS) alert can provide real-time provider support to offer pre-exposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV). The purpose of this study was to evaluate provider utilization of a PrEP CDS alert in a large academic-community pediatric network and assess the association of the alert with PrEP prescribing rates.

METHODS

HIV test orders were altered for patients 13 years and older to include a hard-stop prompt asking if the patient would benefit from PrEP. If providers answered "Yes" or "Not Sure," the CDS alert launched with options to open a standardized order set, refer to an internal PrEP specialist, and/or receive an education module. We analyzed provider utilization using a frequency analysis. The rate of new PrEP prescriptions for 1 year after CDS alert implementation was compared with the year prior using Fisher's exact test.

RESULTS

Of the 56 providers exposed to the CDS alert, 70% (n = 39) responded "Not sure" to the alert prompt asking if their patient would benefit from PrEP, and 54% (n = 30) chose at least one clinical support tool. The PrEP prescribing rate increased from 2.3 prescriptions per 10,000 patients to 6.6 prescriptions per 10,000 patients in the year post-intervention (p = 0.02).

CONCLUSION

Our findings suggest a knowledge gap among pediatric providers in identifying patients who would benefit from PrEP. A hard-stop prompt within an HIV test order that offers CDS and provider education might be an effective tool to increase PrEP prescribing among pediatric providers.

'Stat' workflow modifications to expedite care after needlestick injuries

BACKGROUND

Post-exposure prophylaxis (PEP) for human immunodeficiency virus (HIV) is recommended to start within hours of needlestick injuries (NSIs) among healthcare workers (HCWs). Delays associated with awaiting the results of testing from the source patient (whose blood was involved in the NSI) can lead to psychological consequences for the exposed HCW as well as symptomatic toxicities from empiric PEP.

AIMS

After developing a 'stat' (immediate) workflow that prioritized phlebotomy and resulting of source patient bloodwork for immediate handling and processing, we retrospectively investigated whether our new workflow had (i) decreased HIV order-result interval times for source patient HIV bloodwork and (ii) decreased the frequency of HIV PEP prescriptions being dispensed to exposed HCWs.

METHODS

We retrospectively analysed NSI records to identify source patient HIV order-result intervals and PEP dispensing frequencies across a 6-year period (encompassing a 54-month pre-intervention period and 16-month post-intervention period).

RESULTS

We identified 251 NSIs, which occurred at similar frequencies before versus after our intervention (means 3.54 NSIs and 3.75 NSIs per month, respectively). Median HIV order-result intervals decreased significantly (P < 0.05) from 195 to 156 min after our intervention, while the proportion of HCWs who received one or more doses of PEP decreased significantly (P < 0.001) from 50% (96/191) to 23% (14/60).

CONCLUSION

Using a 'stat' workflow to prioritize source patient testing after NSIs, we achieved a modest decrease in order-result intervals and a dramatic decrease in HIV PEP dispensing rates. This simple intervention may improve HCWs' physical and psychological health during a traumatic time.

Appropriateness of antibiotic selection for pneumonia in the emergency department: pre- and post-order set changes

OBJECTIVES

Emergency department (ED) providers face pressure to meet sepsis mandates such as prompt administration of antibiotic therapy, which can lead to the overuse of broad-spectrum antibiotics. In recent years, there has also been a push to adhere to institutional antibiotic stewardship goals including decreasing inappropriate antibiotic therapy and limiting duration of therapy. Previous literature has demonstrated that the incorporation of clinical decision support (CDS) tools in electronic medical records can aid in guiding appropriate antibiotic prescribing. Therefore, the objective of this study was to determine whether the implementation of a CDS tool could improve antibiotic selection for pneumonia management in the ED.

METHODS

This was a retrospective single-centre observational study conducted in patients that presented to the ED with pneumonia. In November 2018, a CDS tool was incorporated into the ED sepsis order set to guide practitioners in selecting appropriate antibiotics for pneumonia. Antibiotic prescribing patterns were assessed pre-CDS (January-February 2018) and post-CDS (January-February 2019) implementation. Patients were included if they were 18 years of age or older, had an ED visit with ICD10 code reflective of pneumonia, and had at least one antibiotic ordered from the ED sepsis order set. The primary endpoint was the percentage of patients prescribed appropriate antibiotic therapy for pneumonia based on patient risk factors pre- and post-CDS implementation.

KEY FINDINGS

There were 161 patients in the pre-CDS group and 119 patients in the post-CDS group included in the study. There was a significant improvement in the selection of appropriate antibiotics in the post-CDS group (31.9% versus 65.3%, P < 0.0001) with no significant differences in duration of antibiotics, intubation rates, vasopressor initiation, length of stay, mortality or 30-day readmission.

CONCLUSION

The implementation of a CDS tool for empiric management of pneumonia in the ED significantly improved the selection of appropriate antibiotics.

Insulin Bolus Calculator: Lessons Learned from Institutional Experience

Insulin bolus calculators have proven effective in improving glycemia and patient safety. Insulin calculators are increasingly being implemented for inpatient hospital care. Multidisciplinary teams are often involved in the design and review of the efficacy and utilization for these calculators. At times, unintended consequences and benefits of utilization are found on review. Integration of our insulin calculator into our electronic health record system was a multidisciplinary effort. During implementation, several obstacles to effective care were identified and are discussed in the following manuscript. We describe the barriers to utilization and potential pitfalls in clinical integration. We further describe benefits in patient education, time of insulin administration versus meal delivery, variations in insulin bolus for ketone correction, variation in care, and maximum bolus administration. Sharing lessons learned from experiences using electronic insulin calculator order sets will further our goals of improved patient care in the hospital setting.

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

Improving the Management of Terminal Delirium at the End of Life

Objective:

Terminal delirium is a distressing process that occurs in the dying phase, often misdiagnosed and undertreated. A hospital developed the “comfort measures order set” for dying patients receiving comfort care in the final 72 h of life. A chart review of patients experiencing terminal delirium revealed that the current medication option initially included in the order set was suboptimally effective and patients with terminal delirium were consistently undertreated. The purpose of this pilot study was to highlight an in-service intervention educating nurses on the management of terminal delirium at the end of life and to assess its effect on their knowledge of the management of patients with terminal delirium.

Methods:

A before-and-after survey design was used to assess the effect of the in-service training on nurses' knowledge of terminal delirium.

Results:

We describe the results from a small sample of nurses at a large urban tertiary care center in Canada. Of the twenty nurses who attended the in-services, 60% had cared for a patient with terminal delirium; however, 50% felt that their knowledge of the topic was inadequate. Despite no statistical significance between the pre- and posttest scores for both the oncology and the medicine unit nurses, all participants who completed posttest survey found the in-services useful.

Conclusions:

The findings from this study provide initial insights into the importance of in-service trainings to improve the end-of-life care and nursing practice. Future research will include expanding this pilot project with sufficient power to assess the significance of these types of interventions.

Electronic Health Record-Assisted Reflex Urine Culture Testing Improves Emergency Department Diagnostic Efficiency

The authors evaluated the effectiveness of an electronic health record (EHR)-based reflex urine culture testing algorithm on urine test utilization and diagnostic yield in the emergency department (ED). The study implemented a reflex urine culture order with EHR decision support. The primary outcome was the number of urine culture orders per 100 ED visits. The secondary outcome was the diagnostic yield of urine cultures. After the intervention, the mean number of urine cultures ordered was 5.95 fewer per 100 ED visits (9.3 vs 15.2), and there was a decrease in normal, or negative, cultures by 2.42 per 100 ED visits. There also was a statistically significant decrease in urine culture utilization and an increase in the positive proportion of cultures. Simple EHR clinical decision-support tools along with reflex urine culture testing can significantly reduce the number of urine cultures performed while improving diagnostic yield in the ED.

Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit

OBJECTIVE

To assess safety and efficacy compared to a historical cohort. Clinical practice guidelines recommend that patients with diabetic ketoacidosis (DKA) be treated with a standardized protocol. We created a multifaceted order set to promote best-practice management of DKA.

METHODS

We performed a retrospective cohort study of admissions to internal medicine for DKA in adults during a 4.5-year period; 2.25 years before and after order-set initiation. Groups were compared using independent samples t tests and Pearson chi-square or Fisher exact test (categorical data). The Mann-Whitney U test was used for continuous data not normally distributed.

RESULTS

The order-set cohort consisted of 47 admissions, 72.3% with type 1 and 27.7% with type 2 diabetes. The historical cohort consisted of 59 admissions, 69.5% with type 1 and 30.5% with type 2 diabetes. There were no significant differences in initial laboratory values between patients with type 1 and type 2 diabetes in both cohorts. The median length of hospital stay approached significance in the order-set cohort: 3.53 days (2.5 to 5.1); in the historical cohort, the median length of stay was 4.6 days (2.44 to 8.99) (p=0.102).

CONCLUSION

A standardized DKA order set was as effective and safe in type 1 and type 2 diabetes as individual physician management in an academic care setting. Further study is needed to assess its value in community hospital settings with less expertise and fewer diabetes specialty services.

Evaluation of Appropriate Sodium Polystyrene Sulfonate Use With a Hyperkalemia Order Set: A Pilot Study

BACKGROUND

No consensus guidelines exist to assist practitioners in the management of hyperkalemia. Sodium polystyrene sulfonate (SPS) is a common treatment option for hyperkalemia. To aid health-care professionals, a hyperkalemia order set was created at a 979-bed community teaching hospital.

OBJECTIVE

The objective of this study was to determine whether use of a hyperkalemia order set is associated with appropriate use of SPS.

METHODS

Orders for SPS were evaluated for appropriateness in this retrospective cohort of adult patients. Data were collected from December 1, 2015, to December 31, 2016. All orders for SPS not from an order set were randomly matched to those from the order set in a 2:1 fashion. Appropriate use was defined as potassium level >5.5 mEq/L and no contraindications to use. The primary outcome was the absolute difference in the proportion of patients with appropriate SPS use in the order set group compared to the nonorder set group.

RESULTS

A total of 120 patients were analyzed, 40 in the order set group and 80 in the nonorder set group. Baseline characteristics were similar between the groups. Appropriate use occurred in 97.5% of order set patients compared to 60% in the nonorder set group (P < .001). Use of the order set was associated with a greater reduction in serum potassium, quicker follow-up potassium level, and lower incidence of gastrointestinal adverse effects.

CONCLUSIONS

The use of a hyperkalemia order set is associated with appropriate use of SPS. Requiring the use of the hyperkalemia order set for administration of SPS may enhance patient care and safety.

Implementation of a Clinical Decision Support Alert for the Management of Clostridium difficile Infection

Clostridium difficile infections are common in hospitalized patients and can result in significant morbidity and mortality. It is imperative to optimize the management of C. difficile infections to help minimize disease complications. Antimicrobial stewardship techniques including guidelines, order sets and other clinical decision support functionalities may be utilized to assist with therapy optimization. We implemented a novel alert within our electronic medical record to direct providers to the C. difficile order set in order to assist with initiating therapy consistent with institutional guideline recommendations. The alert succeeded in significantly increasing order set utilization, but guideline compliance was unchanged.