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Proctor A, Lyttle M, Billing J, Shaw P, Simpson J, Voss S, Benger JR. Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis. BMJ Open 2024; 14:e078363. [PMID: 38355171 PMCID: PMC10868315 DOI: 10.1136/bmjopen-2023-078363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care. DESIGN Systematic mapping review and narrative synthesis. DATA SOURCES Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. ELIGIBILITY CRITERIA Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury. DATA EXTRACTION AND SYNTHESIS We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis. RESULTS Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories. CONCLUSION Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.
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Affiliation(s)
| | - Mark Lyttle
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | | | | | | | - Sarah Voss
- Health and Life Sciences, University of the West of England, Bristol, UK
| | - Jonathan Richard Benger
- Academic Department of Emergency Care, The University Hospitals NHS Foundation Trust, Bristol, UK
- Faculty of Health & Life Sciences, University of the West of England, Bristol, UK
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Dorr DA, Richardson JE, Bobo M, D'Autremont C, Rope R, Dunne MJ, Kassakian SZ, Samal L. Provider Perspectives on Patient- and Provider-Facing High Blood Pressure Clinical Decision Support. Appl Clin Inform 2022; 13:1131-1140. [PMID: 35977714 PMCID: PMC9713301 DOI: 10.1055/a-1926-0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 08/11/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypertension, persistent high blood pressures (HBP) leading to chronic physiologic changes, is a common condition that is a major predictor of heart attacks, strokes, and other conditions. Despite strong evidence, care teams and patients are inconsistently adherent to HBP guideline recommendations. Patient-facing clinical decision support (CDS) could help improve recommendation adherence but must also be acceptable to clinicians and patients. OBJECTIVE This study aimed to partly address the challenge of developing a patient-facing CDS application, we sought to understand provider variations and rationales related to HBP guideline recommendations and perceptions regarding patient role and use of digital tools. METHODS We engaged hypertension experts and primary care respondents to iteratively develop and implement a pilot survey and a final survey which presented five clinical cases that queried clinicians' attitudes related to actions; variations; prioritization; patient input; importance; and barriers for HBP diagnosis, monitoring, and treatment. Analysis of Likert's scale scores was descriptive with content analysis for free-text answers. RESULTS Fifteen hypertension experts and 14 providers took the pilot and final version of the surveys, respectively. The majority (>80%) of providers felt the recommendations were important, yet found them difficult to follow-up to 90% of the time. Perceptions of relative amounts of patient input and patient work for effective HBP management ranged from 22 to 100%. Stated reasons for variation included adverse effects of treatment, patient comorbidities, shared decision-making, and health care cost and access issues. Providers were generally positive toward patient use of electronic CDS applications but worried about access to health care, nuance of recommendations, and patient understanding of the tools. CONCLUSION At baseline, provider management of HBP is heterogeneous. Providers were accepting of patient-facing CDS but reported preferences for that CDS to capture the complexity and nuance of guideline recommendations.
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Affiliation(s)
- David A. Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Joshua E. Richardson
- Center for Health Informatics and Evidence Synthesis, RTI International, Chicago, Illinois, United States
| | - Michelle Bobo
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Christopher D'Autremont
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Robert Rope
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, United States
| | - MJ Dunne
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Steven Z. Kassakian
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, United States
| | - Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Shah S, Switzer S, Shippee ND, Wogensen P, Kosednar K, Jones E, Pestka DL, Badlani S, Butler M, Wagner B, White K, Rhein J, Benson B, Reding M, Usher M, Melton GB, Tignanelli CJ. Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study. JMIR Med Inform 2021; 9:e30743. [PMID: 34550900 PMCID: PMC8604256 DOI: 10.2196/30743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/17/2021] [Accepted: 09/17/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Studies evaluating strategies for the rapid development, implementation, and evaluation of clinical decision support (CDS) systems supporting guidelines for diseases with a poor knowledge base, such as COVID-19, are limited. OBJECTIVE We developed an anticoagulation clinical practice guideline (CPG) for COVID-19, which was delivered and scaled via CDS across a 12-hospital Midwest health care system. This study represents a preplanned 6-month postimplementation evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. METHODS The implementation outcomes evaluated were reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission with clinical outcomes was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to intensive care unit (ICU) admission. The models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir treatment, tocilizumab treatment, steroid treatment, BMI, Elixhauser comorbidity index, oxygen saturation/fraction of inspired oxygen ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients who had laboratory values (D-dimer, C-reactive protein, creatinine, and absolute neutrophil to absolute lymphocyte ratio) present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission. RESULTS A total of 2503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was the highest at hospitals that were specifically transformed to only provide care to patients with COVID-19 (COVID-19 cohorted hospitals; 74%-82%) and the lowest in academic settings (47%-55%). CPG delivery via the CDS system was associated with improved adherence (odds ratio [OR] 1.43, 95% CI 1.2-1.7; P<.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU admission within 48 hours (OR 0.39, 95% CI 0.30-0.51; P<.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients who received adherent versus nonadherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours; log-rank test P<.001). CONCLUSIONS Our institutional experience demonstrated that adherence with the institutional CPG delivered via the CDS system resulted in improved clinical outcomes for patients with COVID-19. CDS systems are an effective means to rapidly scale a CPG across a heterogeneous health care system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units.
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Affiliation(s)
- Surbhi Shah
- University of Minnesota, Minneapolis, MN, United States
| | - Sean Switzer
- University of Minnesota, Minneapolis, MN, United States
| | | | - Pamela Wogensen
- Information Technology, Fairview Health Services, Minneapolis, MN, United States
| | - Kathryn Kosednar
- Information Technology, Fairview Health Services, Minneapolis, MN, United States
| | - Emma Jones
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Deborah L Pestka
- College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Sameer Badlani
- Information Technology, Fairview Health Services, Minneapolis, MN, United States
| | - Mary Butler
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Brittin Wagner
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Katie White
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Bradley Benson
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Mark Reding
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Michael Usher
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
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Mann D, Hess R, McGinn T, Richardson S, Jones S, Palmisano J, Chokshi SK, Mishuris R, McCullagh L, Park L, Dinh-Le C, Smith P, Feldstein D. Impact of Clinical Decision Support on Antibiotic Prescribing for Acute Respiratory Infections: a Cluster Randomized Implementation Trial. J Gen Intern Med 2020; 35:788-795. [PMID: 32875505 PMCID: PMC7652959 DOI: 10.1007/s11606-020-06096-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clinical decision support (CDS) is a promising tool for reducing antibiotic prescribing for acute respiratory infections (ARIs). OBJECTIVE To assess the impact of previously effective CDS on antibiotic-prescribing rates for ARIs when adapted and implemented in diverse primary care settings. DESIGN Cluster randomized clinical trial (RCT) implementing a CDS tool designed to guide evidence-based evaluation and treatment of streptococcal pharyngitis and pneumonia. SETTING Two large academic health system primary care networks with a mix of providers. PARTICIPANTS All primary care practices within each health system were invited. All providers within participating clinic were considered a participant. Practices were randomized selection to a control or intervention group. INTERVENTIONS Intervention practice providers had access to an integrated clinical prediction rule (iCPR) system designed to determine the risk of bacterial infection from reason for visit of sore throat, cough, or upper respiratory infection and guide evidence-based evaluation and treatment. MAIN OUTCOME(S) Change in overall antibiotic prescription rates. MEASURE(S) Frequency, rates, and type of antibiotics prescribed in intervention and controls groups. RESULTS 33 primary care practices participated with 541 providers and 100,573 patient visits. Intervention providers completed the tool in 6.9% of eligible visits. Antibiotics were prescribed in 35% and 36% of intervention and control visits, respectively, showing no statistically significant difference. There were also no differences in rates of orders for rapid streptococcal tests (RR, 0.94; P = 0.11) or chest X-rays (RR, 1.01; P = 0.999) between groups. CONCLUSIONS The iCPR tool was not effective in reducing antibiotic prescription rates for upper respiratory infections in diverse primary care settings. This has implications for the generalizability of CDS tools as they are adapted to heterogeneous clinical contexts. TRIAL REGISTRATION Clinicaltrials.gov (NCT02534987). Registered August 26, 2015 at https://clinicaltrials.gov.
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Affiliation(s)
- Devin Mann
- New York University School of Medicine, New York, NY, USA.
| | - Rachel Hess
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas McGinn
- Hofstra Northwell School of Medicine, New York, NY, USA
| | | | - Simon Jones
- New York University School of Medicine, New York, NY, USA
| | | | | | | | | | - Linda Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Paul Smith
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Abstract
OBJECTIVES This survey aimed to review aspects of clinical decision support (CDS) that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout. METHODS We performed a survey of relevant articles from 2018-2019 addressing CDS and aspects of clinician burnout from PubMed and Web of Science™. Themes were manually extracted from publications that met inclusion criteria. RESULTS Eighty-nine articles met inclusion criteria, including 12 review articles. Review articles were either prescriptive, describing how CDS should work, or analytic, describing how current CDS tools are deployed. The non-review articles largely demonstrated poor relevance and acceptability of current tools, and few studies showed benefits in terms of efficiency or patient outcomes from implemented CDS. Encouragingly, multiple studies highlighted steps that succeeded in improving both acceptability and relevance of CDS. CONCLUSIONS CDS can contribute to clinician frustration and burnout. Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated.
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Affiliation(s)
- Ivana Jankovic
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan H. Chen
- Center for Biomedical Informatics Research and Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Aifah A, Okeke NL, Rentrope CR, Schexnayder J, Bloomfield GS, Bosworth H, Grover K, Hileman CO, Muiruri C, Oakes M, Webel AR, Longenecker CT, Vedanthan R. Use of a human-centered design approach to adapt a nurse-led cardiovascular disease prevention intervention in HIV clinics. Prog Cardiovasc Dis 2020; 63:92-100. [PMID: 32092444 PMCID: PMC7237285 DOI: 10.1016/j.pcad.2020.02.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 02/06/2023]
Abstract
Stakeholder-informed strategies addressing cardiovascular disease (CVD) burden among people living with HIV (PWH) are needed within healthcare settings. This study provides an assessment of how human-centered design (HCD) guided the adaptation of a nurse-led intervention to reduce CVD risk among PWH. Using a HCD approach, research staff guided two multidisciplinary "design teams" in Ohio and North Carolina, with each having five HCD meetings. We conducted acceptability and feasibility testing. Six core recommendations were produced by two design teams of key stakeholders and further developed after the acceptability and feasibility testing to produce a final list of 14 actionable areas of adaptation. Acceptability and feasibility testing revealed areas for adaptation, e.g. patient preferences for communication and the benefit of additional staff to support patient follow-up. In conclusion, along with acceptability and feasibility testing, HCD led to the production of 14 key recommendations to enhance the effectiveness and scalability of an integrated HIV/CVD intervention.
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Affiliation(s)
- Angela Aifah
- New York University Grossman School of Medicine, United States of America.
| | | | - Cynthia R Rentrope
- Frances Payne Bolton School of Nursing, Case Western Reserve University, United States of America
| | - Julie Schexnayder
- Frances Payne Bolton School of Nursing, Case Western Reserve University, United States of America
| | | | - Hayden Bosworth
- Duke University School of Medicine, United States of America; Durham VA Medical Center, United States of America
| | - Kiran Grover
- Duke University School of Medicine, United States of America
| | - Corrilynn O Hileman
- Case Western Reserve University School of Medicine, United States of America; MetroHealth Medical Center, United States of America
| | - Charles Muiruri
- Duke University School of Medicine, United States of America
| | - Megan Oakes
- Duke University School of Medicine, United States of America; Durham VA Medical Center, United States of America
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, United States of America
| | - Chris T Longenecker
- Case Western Reserve University School of Medicine, United States of America; University Hospitals Harrington Heart & Vascular Institute, United States of America
| | - Rajesh Vedanthan
- New York University Grossman School of Medicine, United States of America
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