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Raban MZ, Gates PJ, Gamboa S, Gonzalez G, Westbrook JI. Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review. J Am Med Inform Assoc 2023:7163187. [PMID: 37187160 DOI: 10.1093/jamia/ocad083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/31/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts. MATERIALS AND METHODS We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively. RESULTS We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects. DISCUSSION Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects. CONCLUSION Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.
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Affiliation(s)
- Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter J Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Gamboa
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Gabriela Gonzalez
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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2
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Nelson DR, Keswani M, Finn L, Mahoney K, Genualdi L, Barhight MF. A quality initiative to improve recognition of fluid overload among pediatric ICU patients requiring continuous kidney replacement therapy: preliminary results. Pediatr Nephrol 2023; 38:557-564. [PMID: 35522340 DOI: 10.1007/s00467-022-05584-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Initiation of continuous kidney replacement therapy (CKRT) greater than 20% fluid overload is associated with increased morbidity and mortality. We aimed to reduce the number of patients initiated on CKRT greater than 20% fluid overload by 50% in one year by implementation of a quality improvement initiative. METHODS This is a prospective quality improvement study set in a pediatric ICU of an urban children's hospital of patients initiated on CKRT over 2 years. The intervention included creation of an electronic health record order for daily calculation of net percent fluid overload, incorporation into daily rounds, and education programs tailored to physicians and bedside nursing. We measured adherence with the new order set, percent fluid overload at CKRT initiation, days on CKRT, timing of first nephrology consultation, and death prior to discharge. RESULTS A total of 32% of patients were initiated on CKRT greater than 20% fluid overload pre-initiative and 9% post-initiative, a 72% reduction over 13 months. Patients initiated on CKRT greater than 20% fluid overload had median CKRT course of 8 (IQR 4-14) vs. 22 days (IQR 13.5-62). CONCLUSION Creating a system using EHR with education may reduce initiation of CKRT after development of severe fluid overload. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Delphine R Nelson
- Division of Nephrology, Children's Hospital of Richmond, 1000 E Broad St, Room 5-448, Richmond, VA, 23219, USA.
| | - Mahima Keswani
- Division of Nephrology, Ann & Robert H Lurie Children's Hospital, Chicago, IL, USA
| | - Laura Finn
- Division of Nephrology, Ann & Robert H Lurie Children's Hospital, Chicago, IL, USA
| | - Kalyn Mahoney
- Division of Nephrology, Ann & Robert H Lurie Children's Hospital, Chicago, IL, USA
| | - Lisa Genualdi
- Division of Nephrology, Ann & Robert H Lurie Children's Hospital, Chicago, IL, USA
| | - Mathew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
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Knees M, Mastalerz K, Simonetti J, Berry A. Decreasing Inappropriate Telemetry Use via Nursing-Driven Checklist and Electronic Health Record Order Set. Cureus 2022; 14:e28999. [PMID: 36249623 PMCID: PMC9550181 DOI: 10.7759/cureus.28999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction: Telemetry is ubiquitous in many hospitals despite widely acknowledged limitations, waste, and potential harm associated with inappropriate use. To curb overuse, guidelines such as the 2017 American Heart Association/American College of Cardiology (AHA/ACC) continuous telemetry monitoring practice standards have outlined appropriate telemetry use standards. This study aimed to perform two “plan-do-study-act” (PDSA) cycles and assess whether a nursing (RN)-driven checklist addressing appropriate telemetry use, combined with just-in-time education delivered via an electronic health record (EHR) order set modification, was efficacious in reducing inappropriate telemetry use within a level 1a Veterans Health Administration hospital. Methods: This is a quality improvement intervention study that took place between March 2019 and August 2020. Three cohorts were sequentially studied: a control cohort without any intervention (n = 100), a cohort with only the RN-driven checklist (n = 100), and a cohort with both the RN-driven checklist and an EHR order set modification that provided just-in-time education about telemetry indications (n = 100). Telemetry records were reviewed by a physician to determine indication, duration for each telemetry order, and appropriateness. An order was deemed “appropriate” if it met AHA/ACC classification grade I (telemetry recommended) or IIa/b (telemetry may be considered) and “inappropriate” if it fell under class III (telemetry not recommended). Data were compared between the control cohort and the two intervention cohorts, as well as between intervention cohorts, using Pearson chi-square analysis. A p-value < 0.05 was considered statistically significant. Results: Within the control group, 37% of telemetry orders were deemed inappropriate. After implementation of the RN checklist, a non-statistically significant lower proportion (26%) of orders was deemed inappropriate (p = 0.09). Implementation of the RN checklist, along with the EHR order set, was associated with a significantly lower proportion of inappropriate orders (17%) in comparison to the control cohort (p = 0.001) but not in comparison to the RN checklist cohort (p = 0.12). There was no significant difference in the duration of telemetry use across cohorts. Conclusions: An RN-driven checklist and EHR telemetry order set modification were associated with a decrease in inappropriate telemetry use from 37% to 17%. By prompting the review of telemetry orders via a daily nursing checklist reviewed during bedside interdisciplinary rounds, clinicians received reinforcement regarding appropriate telemetry indications. This education was strengthened by the just-in-time training provided via the EHR order set.
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Kc M, Olson APJ, Wang Q, Lim N. Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000621. [PMID: 33866310 PMCID: PMC8055129 DOI: 10.1136/bmjgast-2021-000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/14/2021] [Accepted: 03/27/2021] [Indexed: 11/08/2022] Open
Abstract
Objective We evaluated the effect on clinical outcomes of implementing a standardised inpatient order set for patients admitted with hepatic encephalopathy (HE). Methods A retrospective review of patients with cirrhosis admitted with HE. Hospital admissions for HE for which the electronic health record (EHR) order set was used were compared with admissions where the order set was not used. Primary outcome was length of hospital stay (LOS). Secondary outcomes were 30-day readmissions, in-hospital complications, in-hospital and 90-day mortality. Results There were 341 patients with 980 admissions over the study period: 263 patients with 736 admissions where the order set was implemented, and 78 patients with 244 admissions where the order set was not implemented. Median LOS was 4 days (IQR 3–8) in the order set group compared with 3 days (IQR 2–7) (p<0.001); incidence rate ratio 1.37 (95% CI 1.20 to 1.57), p<0.001. 30-day readmissions rate was 56% in the order set group compared with 40%, p=0.01; OR for readmission was 1.88 (95% CI 1.04 to 3.43), p=0.04. Hypokalaemia occurred in 46% of admissions with order set use compared with 36%, when the order set was not used; p=0.003, OR 1.72 (95% CI 1.22 to 2.43), p=0.002. No significant differences were seen for in-hospital mortality and 90-day mortality. Conclusion Implementation of an inpatient EHR order set for use in patients with HE was associated with unexpected clinical outcomes including increased LOS and readmissions. The convenience and advantages of standardisation of patient care should be balanced with a degree of individualisation, particularly in the care of medically complex patients. Furthermore, standardised processes should be evaluated frequently after implementation to assess for unintended consequences.
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Affiliation(s)
- Mandip Kc
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA.,Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
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Mozer CL, Bhagat PH, Seward SA, Mason NR, Anderson SL, Byron M, Peirce LB, Konold V, Kumar M, Arora VM, Orlov NM. Optimizing Oral Medication Schedules for Inpatient Sleep: A Quality Improvement Intervention. Hosp Pediatr 2021; 11:327-333. [PMID: 33731336 DOI: 10.1542/hpeds.2020-002261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Hospitalized children experience frequent nighttime awakenings. Oral medications are commonly administered around the clock despite the comparable efficacy of daytime administration schedules, which promote sleep. With this study, we evaluated the effectiveness of a quality improvement initiative to increase the proportion of sleep-friendly antibiotic administration schedules. METHODS Interprofessional stakeholders modified computerized provider order entry defaults for 4 oral antibiotic medications, from around the clock to administration occurring exclusively during waking hours. Additionally, care-team members received targeted education. Outcome measures included the proportion of sleep-friendly administration schedules and patient caregiver-reported disruptions to sleep. Pre- and posteducation surveys were used to evaluate education effectiveness. Balancing measures were missed antibiotic doses and related escalations of care. RESULTS Interrupted time series analysis revealed a 72% increase (interceptpre: 18%; interceptpost: 90%; 95% confidence interval: 65%-79%; P < .001) in intercept for percentage of orders with sleep-friendly administration schedules (orders: n pre = 1014 and n post = 649). Compared with preeducation surveys, care-team members posteducation were more likely to agree that oral medications scheduled around the clock cause sleep disruption (resident: 71% pre, 90% post [P = .01]; nurse: 63% pre, 79% post [P = .03]). Although sleep-friendly orders increased, patient caregivers reported an increase in sleep disruption due to medications (pre 28%, post 46%; P < .001). CONCLUSIONS A simple, low-cost intervention of computerized provider order entry default modifications and education can increase the proportion of sleep-friendly oral antibiotic administration schedules for hospitalized children. Patient perception of sleep is impacted by multiple factors and often does not align with objective data. An increased focus on improving sleep during hospitalization may result in heightened awareness of disruptions.
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Affiliation(s)
- Christine L Mozer
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | | | - Sarah A Seward
- IS Technology and Applications, Children's Wisconsin, West Allis, Wisconsin
| | - Noah R Mason
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | | | - Maxx Byron
- Section of General Internal Medicine, Department of Medicine
| | - Leah B Peirce
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - Victoria Konold
- Infectious Diseases and Virology, Seattle Children's Hospital, Seattle, Washington
| | - Madan Kumar
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois.,Sections of Infectious Diseases and
| | - Vineet M Arora
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois.,Section of General Internal Medicine, Department of Medicine
| | - Nicola M Orlov
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; .,Pediatric Hospital Medicine, Department of Pediatrics and
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Ancker JS, Gossey JT, Nosal S, Xu C, Banerjee S, Wang Y, Veras Y, Mitchell H, Bao Y. Effect of an Electronic Health Record "Nudge" on Opioid Prescribing and Electronic Health Record Keystrokes in Ambulatory Care. J Gen Intern Med 2021; 36:430-437. [PMID: 33105005 PMCID: PMC7878599 DOI: 10.1007/s11606-020-06276-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/28/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Multiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload. OBJECTIVE To estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes. DESIGN Quality improvement quasi-experiment, analyzed as interrupted time series. PARTICIPANTS Adult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers. INTERVENTION In the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription. MAIN MEASURES Proportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions. KEY RESULTS Across the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards. CONCLUSIONS Autocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress. TRIAL REGISTRATION www.ClinicalTrials.gov protocol 1710018646.
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Affiliation(s)
- Jessica S Ancker
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA.
| | - J Travis Gossey
- Physician Organization Information Services, Weill Cornell Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Sarah Nosal
- Institute for Family Health, New York, NY, USA
| | - Chenghuiyun Xu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Samprit Banerjee
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Yuming Wang
- Physician Organization Information Services, Weill Cornell Medicine, New York, NY, USA
| | - Yulia Veras
- Institute for Family Health, New York, NY, USA
| | - Hannah Mitchell
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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