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.
"Many measures have been suggested to bridge this gap. These measures included periodic educational sessions to increase health care providers’ awareness of the necessity of thromboprophylaxis [6,7], incorporating thromboprophylaxis in medical admission order sets  and electronic alerts using computer-based clinical decision support systems . However, the effectiveness of each of these measures is variable and may be questionable. "
[Show abstract][Hide abstract] 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.
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.
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).
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.
"As such, order sets serve primarily as patient care tools, however they may also be a vehicle for quality improvement, and potentially, an educational tool for medical trainees. While studies have evaluated the impact of order sets on provider performance and patient outcomes [4,5], their impact on postgraduate medical trainee (resident) knowledge remains unknown. Printed or computerized order sets may convey new knowledge to physicians or reinforce existing knowledge. "
[Show abstract][Hide abstract] ABSTRACT: Patient care order sets are increasingly being used to optimize care. While studies have evaluated the impact of order sets on provider performance and patient outcomes, their impact on postgraduate medical trainee knowledge remains unknown. We sought to evaluate the impact of order sets on respirology knowledge, order-writing skills, and self-reported learning.
We conducted a prospective before-after study. Postgraduate trainees completing a Respirology rotation at a quaternary-care hospital 6 months before (no order set period) and 12 months after (order set period) order set introduction. Guideline-based admission order sets with educational prompts detailing recommended management of cystic fibrosis and chronic obstructive pulmonary disease were implemented on the respirology ward. Each resident completed a test before and after the rotation assessing knowledge and order-writing. Residents in the order set period additionally completed a questionnaire regarding the impact of order set use on their learning. Analysis: The primary outcome, the difference between pre and post rotation scores was compared between residents in the no order set period and residents in the order set period, using univariate linear regression. Test validity was assessed with a 2-sample t-test, analysis of variance and Pearson's correlation coefficient. Self-reported impact of order set use were descriptively analyzed, and written responses were collated and coded.
Investigators consecutively recruited 11 subjects before and 28 subjects after order set implementation. Residents in the order set period had a greater improvement in post-rotation test scores than residents in the no order set period (p = 0.04); after adjustment for baseline scores, this was not significant (p = 0.3). The questionnaire demonstrated excellent convergent, discriminant and construct validity. Residents reported that order sets improved their knowledge and skills and provided a systematic approach to care.
Order sets do not appear to impair resident education, and may impart a benefit. This will require validation in larger studies and across diseases.
BMC Medical Education 11/2013; 13(1):146. DOI:10.1186/1472-6920-13-146 · 1.22 Impact Factor
"The authors reported that patients admitted with the VTE prophylaxis order set were more likely to be prescribed prophylaxis against VTE than patients admitted with free text orders (44.0% vs 20.6%, p<0.0001).29 Although this intervention doubled the proportion of patients prescribed VTE prophylaxis, the absolute rate remained quite low (table 3), highlighting one of the notable flaws of optional interventions. "
[Show abstract][Hide abstract] ABSTRACT: Background
Venous thromboembolism (VTE) is a common cause of preventable harm for hospitalised patients. Over the past decade, numerous intervention types have been implemented in attempts to improve the prescription of VTE prophylaxis in hospitals, with varying degrees of success. We reviewed key articles to assess the efficacy of different types of interventions to improve prescription of VTE prophylaxis for hospitalised patients.
We conducted a search of MEDLINE for key studies published between 2001 and 2012 of interventions employing education, paper based tools, computerised tools, real time audit and feedback, or combinations of intervention types to improve prescription of VTE prophylaxis for patients in hospital settings. Process outcomes of interest were prescription of any VTE prophylaxis and best practice VTE prophylaxis. Clinical outcomes of interest were any VTE and potentially preventable VTE, defined as VTE occurring in patients not prescribed appropriate prophylaxis.
16 articles were included in this review. Two studies employed education only, four implemented paper based tools, four used computerised tools, two evaluated audit and feedback strategies, and four studies used combinations of intervention types. Individual modalities result in improved prescription of VTE prophylaxis; however, the greatest and most sustained improvements were those that combined education with computerised tools.
Many intervention types have proven effective to different degrees in improving VTE prevention. Provider education is likely a required additional component and should be combined with other intervention types. Active mandatory tools are likely more effective than passive ones. Information technology tools that are well integrated into provider workflow, such as alerts and computerised clinical decision support, can improve best practice prophylaxis use and prevent patient harm resulting from VTE.
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