Computerized physician order entry improves compliance with a manual exchange transfusion protocol in the pediatric intensive care unit

Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion

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.

Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis

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.

Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review

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.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

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.

Computerised decision support systems to promote appropriate use of blood products

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.

Clinical Decision Support for Pediatric Blood Product Prescriptions

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.

Trends in RBC ordering and use after implementing adaptive alerts in the electronic computerized physician order entry system

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.