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Adkins BD, Murfin R, Luu HS, Noland DK. Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion. Vox Sang 2023; 118:746-752. [PMID: 37431735 DOI: 10.1111/vox.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system. MATERIALS AND METHODS An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation. RESULTS The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year. CONCLUSION BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Roberta Murfin
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Hung S Luu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Daniel K Noland
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
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2
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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Varghese J, Kleine M, Gessner SI, Sandmann S, Dugas M. Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review. J Am Med Inform Assoc 2018; 25:593-602. [PMID: 29036406 PMCID: PMC7646949 DOI: 10.1093/jamia/ocx100] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/10/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023] Open
Abstract
Objectives To systematically classify the clinical impact of computerized clinical decision support systems (CDSSs) in inpatient care. Materials and Methods Medline, Cochrane Trials, and Cochrane Reviews were searched for CDSS studies that assessed patient outcomes in inpatient settings. For each study, 2 physicians independently mapped patient outcome effects to a predefined medical effect score to assess the clinical impact of reported outcome effects. Disagreements were measured by using weighted kappa and solved by consensus. An example set of promising disease entities was generated based on medical effect scores and risk of bias assessment. To summarize technical characteristics of the systems, reported input variables and algorithm types were extracted as well. Results Seventy studies were included. Five (7%) reported reduced mortality, 16 (23%) reduced life-threatening events, and 28 (40%) reduced non-life-threatening events, 20 (29%) had no significant impact on patient outcomes, and 1 showed a negative effect (weighted κ: 0.72, P < .001). Six of 24 disease entity settings showed high effect scores with medium or low risk of bias: blood glucose management, blood transfusion management, physiologic deterioration prevention, pressure ulcer prevention, acute kidney injury prevention, and venous thromboembolism prophylaxis. Most of the implemented algorithms (72%) were rule-based. Reported input variables are shared as standardized models on a metadata repository. Discussion and Conclusion Most of the included CDSS studies were associated with positive patient outcomes effects but with substantial differences regarding the clinical impact. A subset of 6 disease entities could be filtered in which CDSS should be given special consideration at sites where computer-assisted decision-making is deemed to be underutilized. Registration number on PROSPERO: CRD42016049946.
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Affiliation(s)
- Julian Varghese
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Maren Kleine
- Bioinformatics/Medical Informatics Department, Bielefeld University, Bielefeld, Germany
| | | | - Sarah Sandmann
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Martin Dugas
- Institute of Medical Informatics, University of Münster, Münster, Germany
- Institute of Medical Informatics, European Research Center for Information Systems (ERCIS), Münster, Germany
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Quaglini S, Sacchi L, Lanzola G, Viani N. Personalization and Patient Involvement in Decision Support Systems: Current Trends. Yearb Med Inform 2017; 10:106-18. [PMID: 26293857 DOI: 10.15265/iy-2015-015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care. METHODS We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support. RESULTS We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness. CONCLUSIONS Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.
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Affiliation(s)
- S Quaglini
- Silvana Quaglini, Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Via Ferrata 5, 27100 Pavia, Italy, Tel: +39 0382 985058, Fax: +39 0382 985060, E-mail:
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Fisher SA, Docherty AB, Doree C, Hibbs SP, Murphy MF, Estcourt LJ. Computerised decision support systems to promote appropriate use of blood products. Cochrane Database Syst Rev 2017; 2017:CD012545. [PMID: 28344512 PMCID: PMC5360230 DOI: 10.1002/14651858.cd012545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effect of computerised decision support systems (DSSs) on transfusion practice.
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Affiliation(s)
- Sheila A Fisher
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Annemarie B Docherty
- Royal Infirmary EdinburghAnaesthesia and Intensive CareLittle France CrescentEdinburghUKEH16 4SA
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Stephen P Hibbs
- Barking, Havering and Redbridge NHS TrustDepartment of Medicine, Queen's HospitalRom Valley WayRomfordUKRM7 0AG
| | - Michael F Murphy
- Oxford University Hospitals NHS Foundation Trust and University of
OxfordNHS Blood and Transplant; National Institute for Health Research (NIHR) Oxford
Biomedical Research CentreJohn Radcliffe HospitalHeadingtonOxfordUK
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
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Adams ES, Longhurst CA. Clinical Decision Support for Pediatric Blood Product Prescriptions. J Pediatr Intensive Care 2016; 5:108-112. [PMID: 31110894 DOI: 10.1055/s-0035-1569996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/07/2015] [Indexed: 10/22/2022] Open
Abstract
Since the beginning of the 20th century, blood products have been used to effectively treat life-threatening conditions. Over time, we have come to appreciate the many benefits along with significant risks inherent to blood product transfusions. As such, recommendations for the safe and effective use of blood products have evolved over time. Current evidence supports the use of restrictive transfusion strategies that can avoid the risks of unnecessary transfusions. In spite of good evidence, there is a considerable amount of variability in transfusion practices across providers. Clinical decision support (CDS) is an effective tool capable of increasing adherence to evidence-based practices. CDS has been used successfully to improve adherence to transfusion guidelines. Pediatric literature demonstrates strong evidence for the use of CDS to improve appropriateness of red blood cell and plasma transfusion utilization. Further studies in more diverse settings with more standardized reporting are needed to provide more clarity around the effectiveness of CDS in blood product prescriptions.
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Affiliation(s)
- Eloa S Adams
- Department of Pediatric Intensive Care Medicine, Kaiser Permanente, Oakland Medical Center, Oakland, California, United States
| | - Christopher A Longhurst
- Department of Pediatrics, Stanford University School of Medicine, Lucille Packard Children's Hospital, Palo Alto, California, United States
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Schor NF. The Electronic Medical Record and Computerized Physician Order Entry: Challenges and Opportunities for Pediatrics. J Pediatr 2016; 176:5-6. [PMID: 27372392 DOI: 10.1016/j.jpeds.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Nina F Schor
- Departments of Pediatrics, Neurology, and Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, NY.
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The Impact of Electronic Decision Support on Transfusion Practice: A Systematic Review. Transfus Med Rev 2015; 29:14-23. [DOI: 10.1016/j.tmrv.2014.10.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/15/2014] [Accepted: 10/17/2014] [Indexed: 12/25/2022]
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McWilliams B, Triulzi DJ, Waters JH, Alarcon LH, Reddy V, Yazer MH. Trends in RBC ordering and use after implementing adaptive alerts in the electronic computerized physician order entry system. Am J Clin Pathol 2014; 141:534-41. [PMID: 24619755 DOI: 10.1309/ajcpen6vht0ecafi] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES To reduce unnecessary RBC transfusions, the computerized physician order entry (CPOE) system was programmed to require prescribers to select an indication for transfusion. An alert appeared if the patient's hemoglobin (Hb) level was above the threshold determined by the selected indication (adaptive alerts). METHODS Data on RBC orders from the 4 months before the adaptive alerts were implemented were compared with the 10 months after implementation. RESULTS Significantly fewer alerts were generated after the implementation, and the rate at which the alerts were heeded also increased. There was a trend toward fewer RBC units transfused after adaptive alert implementation. A large number of RBCs were ordered using a nonspecific transfusion indication, although many of these patients had antecedent Hb values close to the threshold. CONCLUSIONS Electronically generated alerts can reduce but are insufficient to eliminate non-evidence-based transfusions. Analysis of the alerts suggests areas for CPOE improvement.
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Affiliation(s)
- Brian McWilliams
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - Darrell J. Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
- The Institute for Transfusion Medicine, Pittsburgh, PA
| | - Jonathan H. Waters
- Departments of Anesthesiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Louis H. Alarcon
- Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Vivek Reddy
- Neurology, University of Pittsburgh, Pittsburgh, PA
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
- The Institute for Transfusion Medicine, Pittsburgh, PA
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