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Clinical Guideline Implementation with Order Sets in a Commercial Emergency Department Information S

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Acknowledgements: Amy Sheldahl and Douglas Char, MD. On the Other Hand ... Chisolm DJ, McAlearney AS, Veneris S, Fisher D, Holtzlander M, McCoy KS. ... – PowerPoint PPT presentation

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Title: Clinical Guideline Implementation with Order Sets in a Commercial Emergency Department Information S


1
Clinical Guideline Implementation with Order Sets
in a Commercial Emergency Department Information
System
Advancing Practice, Instruction and Innovation
Through Informatics (APIII) Pittsburgh,
Pennsylvania September 11, 2007
  • Phil Asaro, MD
  • Washington University in St. Louis

2
Presentation Outline
  • Our experience - Acute Coronary Syndrome
    Guideline/Order-sets
  • The Guideline/Order-sets
  • Physician survey
  • Ordering behavior
  • Perspective
  • Other reports
  • Published issues

3
Clinical Guidelines
  • Clinical guidelines can improve care
  • Clinicians must be convinced of validity
  • Must be delivered in actionable form at
    appropriate times
  • Various methods of presentation
  • Pre-constructed order-sets
  • Context-specific links
  • Patient-specific guidance
  • Immediate feedback - alerts and reminders

4
Patterns of Guideline Adherence and Care Delivery
for Patients with Unstable Angina and
NonST-segment Elevation Myocardial Infarction
(From the CRUSADE Quality Improvement
Initiative) Pierluigi Tricoci, MD, MHS, Eric D.
Peterson, MD, MPH, and Matthew T. Roe, MD,
MHS Can Rapid Risk Stratification of Unstable
Angina Patients Suppress Adverse Outcomes with
Early Implementation of the American College of
Cardiology/American Heart Association Guidelines
(CRUSADE) A rapid-cycle quality-improvement
initiative American College of Cardiology
(ACC) American Heart Association (AHA) Am J
Cardiol 200698suppl30Q35Q
5
CRUSADE
  • At the hospital level
  • for each 10 increase in the composite adherence
    to the ACC/AHA guidelines, there was a 10
    decrease in the odds of in-hospital mortality

6
Acute Coronary Syndrome (ACS) ED Guideline /
Order-sets
  • Joint effort - cardiology and EM over 6 months
  • Preprinted paper order forms
  • Check-off orders
  • Fill-in-the-blank
  • Embedded guideline information
  • Four forms each 2-3 pages
  • Initial care and risk stratification all
    patients
  • Three risk-specific forms
  • Expected use
  • Initial order set form one risk-specific order
    set form

7
  • Problem
  • Released the paper forms just a few months before
    CPOE implementation was to eliminate all paper
    orders

8
BACKGROUND
  • Barnes-Jewish Hospital
  • Large, urban, academic, tertiary care medical
    center
  • EDIS is Healthmatics ED (HMED)
  • Allscripts (acquired with A4 Health Systems)
  • Incremental implemention
  • Original implementation September 2001
  • CPOE including electronic order sets May 2003

9
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10
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11
What We Had To Work With
  • Problem oriented order-sets
  • Three-level hierarchy
  • Order-set name (problem based)
  • Orders or Subheading (Lab, Medication, etc.)
  • Orders
  • Globe - URL link at bottom of screen
  • We placed pdfs of the paper forms there

12
Unopened Order-Sets Abdominal Pain Chest
Pain Criteria CP/ACS/MI Initial Orders
CP/STEMI Orders CP/ACS High/Mod Risk Orders
CP/ACS Low Risk Orders Extremity Trauma
Female GU
13
Abdominal Pain Chest Pain Criteria Acute
MI w/ ST elev Ischem Sx AND one of ST elev
in 2 contiguous ---precordial leads ST elev,
1mm or more ---in 2 limb leads New/unknown
LBBB ST depr, more than 2mm ---in V1 and
V2 ST elev V2, V3 w/ 1mm ---ST depr II, AVF,
V6 Call MI team 253-1579 ACS High Risk
Criteria ACS Mod Risk Criteria ACS Low
Risk Criteria AMI Fibrinolytic Criteria
CP/ACS/MI Initial Orders CP/STEMI Orders
14
CP/ACS/MI Initial Orders Initial 12 lead ECG
STAT Repeat ECG STAT Cardiac Monitor NIBP Pulse
Oximetry VS prn Notify SBP GT 180 or LT
90 Notify HR GT 120 or LT 50 Diet NPO Activity
Bedrest O2 _at_ 2L/min NC sat LT 90 CXR-PA/lat CXR-po
rt (if unstable) IV Labs Meds ASA 325mg
chewed (if not allergic) ---if ASA allergy,
consider Clopidogrel 300mg po NTG 0.4mg SL X3 prn
Hold if doing SPECT ---for Low Risk ACS NTG
IV 10mcg/min titrate Nitropaste 0.5in q 6hr x
3d Nitropaste 1.0 in q 6hr x 3d Nitropaste 2.0
in q 6hr x 3d Morphine 2mg IV X3 prn Ibuprofen
600 mg po now APAP 1000 mg po now
15
Anonymous Surveys
  • Pre-CPOE - paper version
  • Post-CPOE - CPOE version
  • Surveys distributed
  • At an EM weekly conference
  • Mailboxes

16
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17
Mean Survey Responses Attending vs. Resident
18
Risk Stratification Criteria
  • Opened 6 times in 97 patients
  • Only 3 times with expected use pattern

19
Correlation with level of training Spearmans Rho
(p-value)
20
Chart Reviews
  • Selection criteria - ED diagnosis of MI, ACS, or
    unstable angina
  • Four one-month periods
  • Before guideline simple chest pain orders
    available
  • After paper guideline released - before CPOE
  • Beginning one month after CPOE implementation
  • Beginning three months after CPOE implementation
  • Retrospective chart reviews
  • Risk-stratification criteria
  • Order-set use
  • Compliance with the guideline recommendation for
    ß-blocker use

21
Order-set use by phase of study
22
Beta-Blocker Orders by Order-Set Use and Phase
Patients without contraindication to a ß-Blocker
(heart block, hypotension, or bradycardia)
23
Summarizing Our Experience
  • Minimal actual use of criteria lists
  • Suboptimal use of the order sets
  • Overall unchanged ordering behavior
  • Less than enthusiastic survey responses
  • Our attempt at guideline implementation using
    CPOE order-sets in a commercial information
    system lacking more advanced decision-support
    functionality was not effective
  • However.
  • Less experienced physicians appear more open to
    guidance offered in the information system
  • Acknowledgements Amy Sheldahl and Douglas Char,
    MD

24
On the Other Hand
25
Improving Patient Care And Medical Workflow Using
Evidence Based Order Sets
  • AMIA Annual Symp Proceedings 2005, 1063
  • Chris O'connor , Katherine Decaire , Jan
    Friedrich
  • Trillium Health Center

26
Results Paper Order Sets
27
Conclusion
  • Order sets are an effective method to improve
    compliance with evidence based practice and
    improve order quality in a voluntary paper based
    order system without the need for significant
    education.

28
Congestive Heart Failure Management Use of
Electronic Order Entry to Enhance Practice
Guideline Compliance
  • AHA 5th Scientific Forum on Quality of Care in
  • Cardiovascular Disease and Stroke,
  • Washington, DC May 16, 2004 (Poster
    Presentation)
  • Raymond Dusman, Carolyn Hart, Doug Horner,
  • Jerry Mourey, Karl LaPan, Mark OShaughnessy,
  • Robert Plant, David Schleinkofer, Michael Mirro
  • Fort Wayne Cardiology / Parkview Research Center
  • Fort Wayne, IN

29
Results
  • ACE Inhibitor use increased
  • From 52.3 (508 of 971) to 85.2 (248 of 291)
  • Beta Blocker use increased
  • From 49.1 (477 of 971) to 80.1 (233 of 291)
  • Spironolactone use in eligible Class III and IV
    patients increased
  • From 95.8 (207 of 216) to 100 (75 of 75)

30
The Role Of Computerized Order Sets In Pediatric
Inpatient Asthma Treatment
  • Pediatr Allergy Immunol 2006 17 199206
  • Chisolm DJ, McAlearney AS, Veneris S, Fisher D,
    Holtzlander M, McCoy KS.
  • Columbus Children's Research Institute
  • Ohio State University

31
Results
32
Other Order Set Successes
  • DVT prophylaxis
  • Peri-operative antibiotic compliance
  • Pain management
  • Glucose management
  • Anticoagulation management

33
Integrating "Best of Care" Protocols into
Clinicians' Workflow via Care Provider Order
Entry Impact on Quality-of-Care Indicators for
Acute Myocardial Infarction
  • J Am Med Inform Assoc. 200613188-196
  • Asli Ozdas, PhD, Theodore Speroff, PhD, L.
    Russell Waitman, PhD, Judy Ozbolt, PhD, Javed
    Butler, MD and Randolph A. Miller, MD
  • Vanderbilt University Hospital

34
  • Existing order entry system with ACS order sets
  • Intervention studied -- a CDS mechanism to direct
    physicians to appropriate order sets when writing
    admission orders
  • ACS order set use - suspected MI
  • 60 (189 of 313) ? 70 (161 of 227)
  • B-blocker use
  • 70 ? 78 (not quite statistically significant)

35
A Survey Of Factors Affecting Clinician
Acceptance Of Clinical Decision Support
  • BMC Medical Informatics and Decision Making 2006,
    66
  • Dean F Sittig, Michael A Krall, Richard H
    Dykstra, Allen Russell and Homer L Chin
  • Kaiser Permanente

36
Factors Considered
  • Patient
  • reason for visit acute vs. chronic
  • severity of illness number of medications,
    number of chronic conditions
  • age
  • Provider
  • age, gender
  • number of years with Kaiser Permanente
  • Alert
  • type of alert
  • number of alerts received
  • Environment
  • presence of a computer in exam room
  • clinician behind schedule

37
Pertinent Results
  • Patient factors
  • CDS more acceptable when patient is elderly, has
    multiple medications, has chronic conditions
  • CDS less acceptable when visit for acute
    condition (Productivity vs. Prevention)
  • Environmental factors
  • Clinicians often behind schedule
  • CDS less acceptable when behind schedule
  • In principle CDS most helpful when clinician is
    least apt to remember

38
Specificity Of Computerized Physician Order Entry
Has A Significant Effect On The Efficiency Of
Workflow For Critically Ill Patients
  • Crit Care Med 2005 33110 114)
  • Naeem A. Ali, MD Hagop S. Mekhjian, MD P. Lynn
    Kuehn, RN, MS Thomas D. Bentley, RN, MS Rajee
    Kumar, PhD
  • Amy K. Ferketich, PhD Stephen P. Hoffmann, MD
  • The Ohio State University Health System

39
  • CPOE deployed in a rapid system-wide approach
  • Initially implemented in MICU with generic
    order sets not designed specifically for the
    ICU
  • A striking number of problems occurred early and
    persistently after implementation in the MICU,
    unlike other units in the hospital
  • MICU returned to paper until further analysis and
    development of specific order sets
  • Subsequently CPOE was implemented in the MICU
    with success

40
Reflecting back to the paper ordering
world Written orders, by convention, had been
condensed to very simplified shorthand that
facilitated their entry. However, it was with a
combination of nurse interpretation and verbally
issued clarifications that the request was
matched to standard unit practice this
shorthand may have made care more efficient but
also less precise, potentially affecting patient
safety.
41
Reflecting on the new CPOE world with appropriate
order sets We believe that streamlined CPOE
ordering aided in standardizing the process of
patient care and both benefited patients by
introducing best practices and practitioners by
facilitating their efficiency.
42
Viewpoint Controversies Surrounding Use of Order
Sets for Clinical Decision Support in
Computerized Provider Order Entry
  • J Am Med Inform Assoc. 20071441-47
  • Anne M. Bobb, BS Pharm, Thomas H. Payne, MD
  • and Peter A. Gross, MD
  • From a collection of manuscripts in the Jan/Feb
    2007 issue of JAMIA produced by a 2005 conference
    on CDS in CPOE

43
1
  • most CPOE systems make the utilization of order
    sets for any given patient voluntary for
    clinician-users
  • patients do not benefit when their care
    providers bypass evidence-based order sets usage

44
Related Comments
  • Smart system to suggest an order set based on
    complaint or other patient-specific information
    in the electronic record
  • Default orders within an order set
  • All orders
  • Select orders
  • Medication orders?

45
2
  • CPOE vendors and free-standing vendors supply
    "evidence-based" order sets for CPOE customers
  • it is difficult for institutions to adopt order
    sets from other institutions

46
2
  • Until a national-standard set of defined CPOE
    orderables is developed, to which each vendor or
    institution can map their own "orderables at
    both the order name and individual fields
    levelslittle progress may be made

47
3
  • there remain significant limitations to what
    CPOE-based order sets can do

48
Desirable Functionality
  • Linked orders
  • Begin together e.g. monitoring lab orders
  • Discontinue at same time e.g. PCA, heparin
    protocols
  • Mutually exclusive alternate AB
  • Patient-specific dose calculations based on
    weight, age, or body surface area
  • Ideally would also consider
  • currently active medications
  • current laboratory results
  • Pop-up" algorithmic "advisors" that go beyond
    the capabilities of order sets to take dynamic
    patient states into consideration

49
4
  • While evidence-based order sets can make it
    easier for CPOE clinician-users to "do the right
    thing," clinical knowledge advances rapidly
  • When order sets are implemented without
    organization standards and clinical review or
    inadequately maintained, they become templates
    for efficiently practicing outdated medicine on a
    widespread basis

50
Then Again
  • Many times clinical practice changes are
    recognized at the clinician level, but never
    communicated to the group managing order sets in
    the system. Clinicians create standard
    work-arounds to meet their needs and train their
    residents and others to use the work-around, thus
    reverting to reliance on memory and increasing
    the risk of error

51
5
  • Allow individual clinicians to develop their own
    "private" order sets?
  • Potentially removes the evidence-based nature of
    order sets, and introduces other maintenance
    issues

52
CRUSADE
  • Paradoxical Care
  • Patients with higher risk of adverse outcomes are
    expected to have a greater absolute benefit from
    aggressive therapies.
  • CRUSADE analyses have reported that the
    highest-risk patients are less likely to be
    adequately treated.

53
CRUSADE
  • About 15 of patients with NSTE ACS have
    moderate-to-severe chronic kidney disease
  • These patients are older and have more
    comorbidities, such as diabetes, heart failure
    and prior history of coronary artery disease
  • Concerns about complications from antithrombotic
    drugs and invasive procedures may at least
    partially explain lower guideline compliance
  • -- data regarding efficacy and safety in these
    subpopulations is lacking.

54
CRUSADE
  • Among the strongest predictors of blood
    transfusion use in patients with NSTE ACS
  • renal insufficiency
  • advanced age

55
CRUSADE
  • Medication overdosing was associated with a
    significant increase in major bleeding
  • --dose response effect
  • degree of excess dose
  • number of drugs administered in excess
  • 42 of patients with NSTE ACS received an initial
    dose in excess of that recommended of at least
    one of
  • unfractionated heparin
  • low-molecular-weight heparin
  • GP IIb/IIIa inhibitor

56
Desirable Functionality
  • Linked orders
  • Begin together e.g. monitoring lab orders
  • Discontinue at same time e.g. PCA, heparin
    protocols
  • Mutually exclusive alternate AB
  • Patient-specific dose calculations based on
    weight, age, or body surface area
  • Ideally would also consider
  • currently active medications
  • current laboratory results
  • Pop-up" algorithmic "advisors" that go beyond
    the capabilities of order sets to take dynamic
    patient states into consideration

57
CRUSADE
  • Even simple and harmless interventions are
    underused among patients with chronic kidney
    disease
  • smoking cessation, counseling, dietary
    modification, and referral to cardiac
    rehabilitation
  • May reflect the lack of outcome expectancy in
    this subset of patients.

58
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59
In Conclusion
  • Guidelines can improve care
  • Order-sets can make it easier for clinicians to
    do the right thing
  • Technology is exciting and wonderful
  • Better tools are needed
  • Focus attention on critical decisions
  • Provide additional information at key decision
    points
  • Clinician acceptance important
  • Convincing evidence of safety and efficacy
  • Must be seen as improving clinician workflow, not
    interfering
  • Go for the low hanging fruit
  • Keep working on the harder stuff
  • Push vendors to improve functionality
  • Certification of HIT should help

60
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61
  • Phil Asaro
  • Washington University in St. Louis
  • asarop_at_msnotes.wustl.edu
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