1
|
Baugh CW, Cash RE, Meguerdichian D, Dunham L, Stump T, Stevens R, Reust A, White B, Dutta S. An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients. Ann Emerg Med 2024; 83:24-34. [PMID: 37725025 DOI: 10.1016/j.annemergmed.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/21/2023]
Abstract
STUDY OBJECTIVE The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units. METHODS We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect. RESULTS Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37). CONCLUSION An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.
Collapse
Affiliation(s)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Lisette Dunham
- Clinical Informatics, Mass General Brigham Digital, Boston, MA
| | - Timothy Stump
- Clinical Informatics, Mass General Brigham Digital, Boston, MA
| | - Ronelle Stevens
- Mosaic Inpatient Applications, Boston Children's Hospital, Boston, MA
| | - Audrey Reust
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA
| | - Benjamin White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Sayon Dutta
- Clinical Informatics, Mass General Brigham Digital, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
2
|
Ouchi K, George N, Revette AC, Hasdianda MA, Fellion L, Reust A, Powell LH, Sudore R, Schuur JD, Schonberg MA, Bernstein E, Tulsky JA, Block SD. Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department. J Palliat Med 2018; 22:267-273. [PMID: 30418094 DOI: 10.1089/jpm.2018.0360] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting. OBJECTIVE To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED. DESIGN Prospective intervention development study. SETTING In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate. MEASUREMENTS Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning. RESULTS We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care. CONCLUSION An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.
Collapse
Affiliation(s)
- Kei Ouchi
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Naomi George
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Anna C Revette
- 5 Survey and Data Management Core for Qualitative and Quantitative Research, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Mohammad Adrian Hasdianda
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Lauren Fellion
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Audrey Reust
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Lynda H Powell
- 6 Department of Preventive Medicine, Rush Medical College , Chicago, Illinois
| | - Rebecca Sudore
- 7 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Jeremiah D Schuur
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Mara A Schonberg
- 8 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Edward Bernstein
- 9 The Brief Negotiated Interview Active Referral to Treatment Institute, Boston University School of Public Health , Boston, Massachusetts.,10 Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts
| | - James A Tulsky
- 4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Susan D Block
- 3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,10 Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts.,11 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,12 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts
| |
Collapse
|