The Utilization of Standardized Order Sets Using AASLD Guidelines for Patients With Suspected Cirrhosis and Acute Gastrointestinal Bleeding

Interventions to improve the performance of upper GI endoscopy quality indicators

The promotion of quality and best practices in gastroenterology and endoscopy is an ongoing effort. For upper GI endoscopy, quality indicators derived from clinical studies and expert consensus have been long established but remain variably obtained. To date, data on interventions aimed to improve these indicators are scarce. We systematically reviewed the literature to identify interventions and measures demonstrated to improve the performance of previously established upper endoscopy quality indicators. We also identified evidence gaps and opportunities for improvement in this area.

The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial

BACKGROUND

Liver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta.

METHODS

A mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework.

DISCUSSION

The CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in "real-world" conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04149223, November 4, 2019.

Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets

OBJECTIVE

This study describes the impact of modifications to a general admission order set on physician prescribing of 2 as-needed or pro re nata (PRN) bedtime sedatives.

METHODS

The hospitalists at our institution have used a general medical admission order set since 2005. Zolpidem was the only as-needed (PRN) bedtime sedative option on the order set until trazodone was added in December 2008. Trazodone is preferred over zolpidem in the geriatric population. We identified patients admitted by the hospitalists between January 2007 and August 2013 who were prescribed with either zolpidem or trazodone as a PRN sedative. Patient demographics, date and time of the order, and number of sedative doses administered during the hospitalization were recorded. Orders placed within 12 hours of admission were attributed to admission orders.

RESULTS

Between 2007 and 2013, the number of patients admitted by the hospitalists with an order for PRN trazodone on admission increased by 18-fold. During the same period, the number of admissions by the hospitalists increased by 2.3 times. Zolpidem orders exceeded those for trazodone in all age groups until 2008. After the addition of trazodone, its use exceeded that of zolpidem. Almost half (48%) of all patients did not have a dose of the PRN trazodone administered.

CONCLUSIONS

Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians' clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation.

Building Effective Quality Improvement Programs for Liver Disease: A Systematic Review of Quality Improvement Initiatives

BACKGROUND & AIMS

Quality indicators are the measurable components of clinical standards. Data are limited about the design and impact of interventions to improve quality indicators for patients with chronic liver disease.

METHODS

A systematic review of PubMed, Web of Science, and conference proceedings was performed to find reports of quality improvement (QI) interventions. Data regarding the several indicators were collected. The search focused on vaccination against hepatitis A or hepatitis B virus, management of spontaneous bacterial peritonitis, screening for varices, management of acute variceal hemorrhage, hepatocellular carcinoma screening, and 30-day readmissions.

RESULTS

Fifteen studies reported on the results of QI interventions. Ten focused on specific quality indicators (1 specific to vaccination, 2 spontaneous bacterial peritonitis, 3 gastrointestinal bleeding, and 4 hepatocellular carcinoma screening); 5 focused on clinical outcomes. Most studies used a pre-post study design. Interventions included checklists, educational conferences, electronic decision supports, nurse coordinators, and systematic changes to facilitate specialist co-management. Successful interventions optimized clinical workflow, closed knowledge gaps among frontline providers, created forced functions in the electronic ordering system, added dedicated staff to manage specific indicators, and provided viable alternatives to hospitalization to reduce readmission. Unsuccessful interventions included case management, phone calls, and home visits to reduce readmissions, checklists, and educational programs.

CONCLUSIONS

Past experience with QI provides generalizable rules for successful future interventions aimed at improved quality indicator adherence and patient outcomes.

Analysis of a Standardized Perioperative Pain Management Order Set in Highly Opioid-Tolerant Patients

OBJECTIVE

The aim was to assess a standardized order set for perioperative pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery.

METHODS

This retrospective chart review evaluated a pain order set in highly opioid-tolerant patients undergoing elective total knee or total hip arthroplasty from January 2010 through August 2012. Based on the date of the surgery, patients were allocated into preimplementation or postimplementation order set groups. The primary outcome assessed whether an adjustment in daily opioid dosage was required within the first 48 hours postoperatively. Secondary outcomes included pain scores, length of hospitalization, and safety outcomes.

RESULTS

Sixty patients were included in the analysis. An adjustment to postoperative opioid therapy occurred in 62% of the patients in the preimplementation group and in 56% of postimplementation group patients (P = 0.786). There were no differences in median pain scores 48 hours postoperatively (P = 0.348). Cumulative toxicity was increased after order set implementation compared with previous patients (44% versus 5%, P < 0.005); however, opioid doses held for sedation was the only individual toxicity to reach statistical significance (P = 0.011).

CONCLUSIONS

This study is the first to evaluate a standardized order set for pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery. The order set demonstrated similar efficacy to previous treatment modalities, but opioid-induced sedation was of concern with the order set. After the initial analysis, the order set was modified to minimize opioid-induced sedation. Continual safety analysis is warranted for quality improvement to enhance perioperative pain management in highly opioid-tolerant patients.

Improving adherence for management of acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Clinical practice guidelines recommend 40-60 mg of prednisone equivalent for 10-14 days for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the amount of corticosteroid prescribed varies widely in clinical practice. Using the electronic health record, we implemented an evidence-based order set to standardize treatment of patients hospitalized with acute exacerbations of COPD.

METHODS

This is a pre- and post-intervention study on patients hospitalized between January 1, 2009 and September 30, 2012 with primary discharge diagnosis of COPD (International Classification of Diseases, 9(th) Revision code: 491.xx, 492.xx, and 496) and receipt of at least one dose of corticosteroid at our tertiary care hospital. Data on baseline demographics, dose of corticosteroid in prednisone equivalent administered during the first 48 hours and during the entire hospitalizations were collected from the electronic health record. Evidence-based guidelines were used to build and implement acute exacerbations of COPD management electronic ordersets in our electronic health record, Epic (Verona, WI). We divided the study into 2 time periods (January 1, 2009 through February 28, 2011 as pre- [n = 203] and March 1, 2011 through September 30, 2012 as post-intervention periods [n = 217]). The primary outcome measure was corticosteroid dose administered in the first 48 hours. Secondary outcome measures were corticosteroid dosage during the entire hospitalization, length of stay, hospital follow-up rates, and 30-day readmission rates.

RESULTS

A total of 420 patients with acute exacerbations of COPD were included in the study. In the post-intervention period, the median amount of corticosteroid used in the first 48 hours was significantly reduced (306.2 mg vs 156.25 mg, P < .0001), as was that used during the entire hospitalization (352.5 mg vs 175 mg, P < .0001). There was no difference in hospital follow-up rates, length of stay, or 30-day readmission rates between the 2 periods.

CONCLUSIONS

Evidence-based electronic ordersets improve compliance with clinical practice guidelines and reduce the total dose of corticosteroid administered in patients hospitalized with acute exacerbations of COPD.