Medical Admission Order Sets to Improve Deep Vein Thrombosis Prophylaxis Rates and Other Outcomes
ABSTRACT The value of order sets for clinical decision support has not been established.
To determine whether introduction of admission order sets increases the proportion of inpatients receiving deep venous thrombosis (DVT) prophylaxis.
General medical patients admitted to hospital.
Paper-based admission order sets (instead of free-text orders) for voluntary use by internists, without any education or behavior change interventions.
Primary outcome was proportion of medical admissions ordered DVT prophylaxis. Secondary outcomes included overall utilization of DVT prophylaxis in medical inpatients and other admission order care quality measures.
Prior to introduction of order sets, DVT prophylaxis was ordered in 10.9% of patients. Patients admitted with order sets were more likely to be ordered DVT prophylaxis than patients admitted with free-text orders (44.0% versus 20.6%, by months 14 and 15, P<0.0001). Hospital-wide DVT prophylaxis in medical inpatients increased from 12.8% to 25.8% of patient-days (P<0.0001). Order set use improved many other secondary outcomes (P<0.05 for all), including allied health consultations (62.8% versus 12.7%), use of standardized diabetic diet (17.0% versus 5.1%), insulin sliding scale (19.1% versus 7.6%), potassium replacement protocol (63.8% versus 0.51%), documentation of allergies (54.3% versus 9.6%) and resuscitation status (57.4% versus 10.2%), and reduced orders for inappropriate laboratory tests such as blood urea nitrogen (39.4% versus 59.0%).
The broad impact of order sets and minimal organizational resources required for their implementation suggests that order sets may have wide applicability as a clinical decision support tool.
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ABSTRACT: National guidelines recommend prophylactic anticoagulation for all hospitalized patients with cancer to prevent hospital-acquired venous thromboembolism (VTE). However, adherence to these evidence-based recommended practice patterns remains low. We performed a quality improvement (QI) project to increase VTE pharmacologic prophylaxis rates among patients with gynecologic malignancies hospitalized for nonsurgical indications and evaluated the resulting effect on rates of development of VTE.International Journal of Gynecological Cancer 10/2014; 25(1). DOI:10.1097/IGC.0000000000000312 · 1.95 Impact Factor
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ABSTRACT: Purpose: Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure is associated with improved patient Process and Outcome quality metrics. Methods: Observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical ICU from 2009 to 2011. The three main protocol updates were: 1. Requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours; 2. Requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily; and 3. Systematic, protocolized de-escalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Pre-specified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay and hospitalization; hospital mortality and ventilator associated pneumonia (VAP) rate. Results: Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% CI, 1.05-1.39; P <0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI 1.08-1.21, P <0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/hour; 0.15 vs. 0.23; P <0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall OR of delirium was 0.67 (95% CI: 0.49-0.91, P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (OR 1.18; 95% CI 0.80-1.76, P = 0.40) was seen. Conclusion: Implementation of an updated ICU analgesia, sedation and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium, median durations of mechanical ventilation, ICU stay and hospitalization.03/2014; 11(3):397. DOI:10.1513/AnnalsATS.201306-210OC
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ABSTRACT: Background Venous thromboembolism (VTE) prophylaxis is underutilized for hospitalized patients. The primary objective of this study was to assess the impact of a continuing medical education (CME) program on thromboprophylaxis and VTE-associated mortality in a tertiary-care hospital. Methods This was a retrospective study of all patients admitted to a tertiary-care hospital from 01/07/2009 to 30/06/2010 (after a CME program that aimed at improving VTE prophylaxis) and had confirmed VTE during stay. VTE prophylaxis utilization and associated mortality were assessed in them and compared to those of a similar cohort of patients hospitalized in the previous 12 months. Results There were 147 confirmed VTE cases in the study period (surgical: 26.5% and medical: 73.5%). Most (63.9%) VTE patients received prophylaxis after the CME program compared with 36.5% in the previous 12 months (relative risk 1.73; 95% confidence interval, 1.38-2.18; P < 0.001). More surgical (82.1%) than medical (57.4%) patients received prophylaxis (P < 0.01). VTE-associated mortality rate was 10.9% with a significant decrease after the CME program (relative risk, 0.52; 95% confidence interval, 0.30-0.90). This mortality was lower for those who received VTE prophylaxis compared to those who didn’t (4.3% and 22.6%, respectively; P < 0.01). Additionally, VTE-associated deaths represented 1.1% of total hospital mortality compared to 1.9% in the 12 months before CME program (relative risk, 0.58; 95% confidence interval, 0.32-1.04; P = 0.07). Conclusions A CME educational program to improve VTE prophylaxis in a tertiary-care hospital was associated with improvement in VTE prophylaxis utilization and VTE-associated mortality. Such programs are highly recommended.Thrombosis Journal 04/2014; 12. DOI:10.1186/1477-9560-12-9 · 1.31 Impact Factor