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.
- [Show abstract] [Hide abstract]
ABSTRACT: To improve the adherence to AASLD (American Association for the Study of Liver Diseases) guidelines for variceal bleeding, we developed and implemented standardized order sets for gastrointestinal bleeding in our hospital on October 1, 2009. We performed medical record reviews of hospitalized patients with gastrointestinal bleeding with suspected cirrhosis from October 2009 to October 2010 to determine the use of octreotide, prophylactic antibiotics, and endoscopy. We reviewed 300 Medical records and identified 26 patients with suspected cirrhosis and gastrointestinal bleeding who had adequate information to determine whether or not the order set was used. Antibiotic was used in 76% of patients, octreotide was used in 76% of patients, and upper endoscopy was completed in 94% of patients within 24 hours. The use of antibiotics was higher than that used in historical controls in our hospital. Implementation of standardized order sets appears to have improved adherence to standard recommendations. However, larger studies with longer follow-ups are needed to evaluate this effect on clinical outcomes and cost of care.Quality management in health care 01/2013; 22(2):146-51. DOI:10.1097/QMH.0b013e31828bc328
- [Show abstract] [Hide abstract]
ABSTRACT: Hospital-acquired (HA) venous thromboembolism (VTE) is a common source of morbidity/mortality. Prophylactic measures are underutilized. Available risk assessment models/protocols are not prospectively validated. Improve VTE prophylaxis, reduce HA VTE, and prospectively validate a VTE risk-assessment model. Observational design. Academic medical center. Adult inpatients on medical/surgical services. A simple VTE risk assessment linked to a menu of preferred VTE prophylaxis methods, embedded in order sets. Education, audit/feedback, and concurrent identification of nonadherence. Randomly sampled inpatient audits determined the percent of patients with "adequate" VTE prevention. HA VTE cases were identified concurrently via digital imaging system. Interobserver agreement for VTE risk level and judgment of adequate prophylaxis were calculated from 150 random audits. Interobserver agreement with 5 observers was high (kappa score for VTE risk level = 0.81, and for judgment of "adequate" prophylaxis = 0.90). The percent of patients on adequate prophylaxis improved each of the 3 years (58%, 78%, and 93%; P < 0.001) and reached 98% in the last 6 months of 2007; 361 cases of HA VTE occurred over 3 years. Significant reductions for the risk of HA VTE (risk ratio [RR] = 0.69; 95% confidence interval [CI] = 0.47-0.79) and preventable HA VTE (RR = 0.14; 95% CI = 0.06-0.31) occurred. We detected no increase in heparin-induced thrombocytopenia (HIT) or prophylaxis-related bleeding using administrative data/chart review. We prospectively validated a VTE risk-assessment/prevention protocol by demonstrating ease of use, good interobserver agreement, and effectiveness. Improved VTE prophylaxis resulted in a substantial reduction in HA VTE.Journal of Hospital Medicine 01/2009; 5(1):10-8. DOI:10.1002/jhm.562 · 2.08 Impact Factor
- Journal of Hospital Medicine 02/2009; 4(2):77-80. DOI:10.1002/jhm.423 · 2.08 Impact Factor