Use of a Cirrhosis Admission Order Set Improves Adherence to Quality Metrics and May Decrease Hospital Length of Stay

Improving Evidenced-based Outpatient Order Set Utilization in the Gastrointestinal Division of a Large Pediatric Health System

Introduction

Standardization is crucial in improving healthcare outcomes, equity and quality. Clinical decision support tools are key to achieving this goal. At our organization, Epic serves as our electronic health record, and SmartSets are Epic's version of outpatient standardized order sets with embedded clinical decision support tools. In 2022, the utilization of SmartSets in our hospital's gastrointestinal division was only 1.9%, far below our organizational target of 50%.

Methods

Our group formed a quality improvement (QI) team and chose the model for improvement methodology. The interventions focused on education, buy-in, feedback performance monitoring, and the enhancement and development of new SmartSets. Our primary aim was to increase the utilization rate of SmartSets by gastrointestinal providers from 1.9% to 20%, and our secondary aim was to reduce the time spent by providers on orders by 10% from 3.3 to 2.8 minutes per encounter. Our balancing measure was monitoring safety reports during the study period.

Results

SmartSet utilization improved to greater than 20% within 7 months of the project initiation. Three months after implementing SmartSet updates and introducing new SmartSets into production, time spent on orders during clinical encounters decreased from a median of 3.3 to 2.4 minutes per encounter. We appreciated that there was no change in safety reporting during the project timeline.

Conclusions

We achieved our goal of improving utilization rates of standardized SmartSets and reducing time spent on orders using a QI methodology. Our achievements underscore the effectiveness of QI methods in enhancing SmartSet utilization and streamlining order processes.

Quality improvement project demonstrating a sustained increase in the assessment and sampling of ascites for hospitalised patients with cirrhosis

Objective

Using quality improvement techniques, we aimed to improve the rate of assessment and sampling of ascitic fluid for the purpose of diagnosing spontaneous bacterial peritonitis in patients with cirrhosis admitted to the hospitalist service of our institution.

Design/methods

Based on stakeholder needs assessment, we implemented interventions targeting provider knowledge, procedure workflows and clinical decision support. We analysed key metrics during preintervention (September-December 2020), intervention roll-out (January-April 2021), postintervention (May-September 2021) and sustainability (September-December 2022) periods for admissions of patients with cirrhosis to our hospitalist service at Maine Medical Center, a 700-bed tertiary-care academic hospital in Portland, Maine, USA.

Results

Among patients with cirrhosis admitted to our service, documentation of assessment for paracentesis increased from a preintervention baseline of 60.1% to 93.5% (p<0.005) postintervention. For patients with ascites potentially amenable to paracentesis, diagnostic paracentesis rate increased from 59.7% to 93% (p<0.005), with the rate of paracentesis within 24 hours increasing from 52.6% to 77.2% (p=0.01). These improvements persisted during our sustainability period. Complication rate was low (1.2%) across all study periods.

Conclusion

Our quality improvement project led to a sustained improvement in the identification of patients with cirrhosis needing diagnostic paracentesis and an increased procedure completion rate. This improvement strategy serves as a model for needed work toward closing a national performance gap for patients with cirrhosis.

Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation

BACKGROUND

Standardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers' perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada.

METHODS

We utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups.

RESULTS

Key findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation.

CONCLUSIONS

Implementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.