Integrating "best of care" protocols into clinicians' workflow via care provider order entry: impact on quality-of-care indicators for acute myocardial infarction

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This article examines the effectiveness of using a decision support tool for integrating the “best of care” order sets for physicians who are admitting patients into the hospital with acute coronary syndrome (ACS) or acute myocardial infarction (AMI). The article also looks at the quality measures for the management of patients with AMI.

Introduction

American Heart Association guidelines for AMI recommend patients receive aspirin and beta-blocker therapy within 24 hrs of admission. Joint Commission and the Center for Medicare and Medicaid Services mandate the use of this protocol to assess and monitor quality of care for patients admitted with AMI.

Methods

The study took place at Vanderbilt University Medical Center where WizOrder is the CPOE with integrated decision support. Orders were often created without the use of evidence-based templates. The authors introduced a tool known as Admission Advisor into the decision support to encourage the use of ACS order sets for aspirin and beta-blocker therapy during admission of patients with suspected AMI and those who were discharged with the diagnosis of AMI. This decision support module was designed to alert the ordering physicians of relevant diagnosis/procedure-specific orders sets during admission.

Authors began the study before the implementation of Admission Advisor for 32 weeks and after implementation for 20 weeks. This allowed them to compare the effect Admission Advisor had on the early prescribing of aspirin and beta-blocker therapy. At the time the study began there was a decision-support module already in place that was used as a discharge-planning tool. This tool implemented AMI discharge guidelines to improve quality of care for AMI patients including order sets for aspirin and beta-blocker therapy at time of discharge.

Results

The results proved that during the pre-intervention period the ACS order set was used in 60% of the patients that were admitted with suspected AMI. After the intervention of Admission Advisor the number increased to 70%. When comparing the before and after evaluation of the intervention there was no direct measurable impact on early therapy. The use of the order sets showed an increase in ordering aspirin early in suspected AMI patients and a nonsignificant increase in the use of beta-blockers. The Admission Advisor showed a significant increase in the use of early aspirin and beta-blocker therapy in patients with suspected AMI.

The implementation of the discharge-planning tool by the institution could have greatly affected the study in regards to the pre and post intervention of Admission Advisor. The discharge-planning tool was designed to target the same therapy as Admission Advisor. Another factor that impacted the study was the use of the ACS order sets by others such as interns, residents, fellows and attending physicians during the patient's hospital stay. The therapy was not always prescribed upon admission by the admitting physician.

Comments

With the intervention of Admission Advisor there was a slight increase in the use of aspirin and beta-blocker therapy in patients upon admission with suspected AMI. Although the increase was not significant compared to the pre-intervention there were factors that could have contributed to this finding.

References

  1. http://www.ncbi.nlm.nih.gov/pubmed/16357360


Ozdas A, Speroff, T, Waitman LR, Ozbolt,J, Butler, J, Miller, RA, Integrating Best of Care Protocols into Clinicians’ Workflow via Care Provider Order Entry: Impact on Quality-of-Carte Indicators for Acute Myocardial Infarction, JAMIA, 13(2) 188-196

Introduction

This study at Vanderbilt University Medical Center sought to review physician response to acute coronary syndrome. The American Heart Association guidelines for acute myocardial infarction (AMI) include prescription of aspirin and a beta blocker during the first 24 hours of care. The authors note that despite the fact that these interventions are well-documented, adherence to these evidence-based practices are inconsistent with substantial regional variation.

WizOrder is the Vanderbilt CPOE system integrated with decision support. The authors of this study developed ‘Admission Advisor’ as a component of decision support related to physician ordering in the case of patients presenting with acute coronary syndrome. The study separated findings between 1) persons who met the criteria of ‘sensitive for AMI’ upon admission and 2) persons who ultimately had confirmed discharge diagnosis of AMI.

Method

The study followed 540 patients. 313 presented during the pre-intervention phase (prior to initiation of ‘Admission Advisor’) and 227 followed during the intervention phase. Of these 540 patients, 180 had confirmed diagnosis of AMI—105 in the pre-intervention phase and 75 in the intervention phase. During the pre-intervention phase, 60% of patients received the recommended medication regimen. With the addition of ‘Admission Advisor,’ this increased to 70%. When the reviewers looked specifically at the group who ultimately had confirmed discharge diagnosis of AMI, there was no significant change in ordering patterns among physicians. Translate: MD’s were no more likely to prescribe aspirin and beta-blockers to the patients who needed them the most regardless of decision support prompts.

A total of 135 physicians admitted these 540 patients. This fact seems to underscore the value of clinical prompts, since the care of these patients was not pooled into a very small group of specialists who would likely have made aspirin and beta-blockers a routine part of their orders.

Discussion

The authors seemed concerned that this seemingly easy-to-order and easy-to-administer medication regimen has not been universally adopted by practitioners. They acknowledge that there are some patients for whom this regimen is contraindicated: persons with active peptic ulcer, allergy to aspirin, or persons with severe asthma or chronic obstructive pulmonary disease which would preclude using beta-blockers.

If the reader is disheartened about the potential of being treated for an AMI at Vanderbilt, some cautions related to the decision-support design should help ease your anxiety. Prompts from ‘Admission Advisor’ were only given to the identified primary physician. In an acute coronary care presentation, many physicians may be involved in writing orders—and not all of these were prompted about ASA and beta blockers. In some cases, the medications were ordered by an alternate physician, including emergency room staff. Thus, the patient received the recommended care, and the attending physician’s ignoring the ‘Admission Advisor’ prompt was because the patient had already received the medication. From a decision-support-design point of view, it is important to build the system so that the right practitioners get the right information based both on the patient’s presentation of illness and the provider’s specialty.

The hospital had initiated an entirely separate campaign to improve compliance with the AHA guidelines prior to this study. Thus, compliance likely had improved prior to the pre-intervention phase of the study, and there was less opportunity to make a ‘significant’ change in ordering practice through ‘Admission Advisor.’

This study validates several general trends found in other studies. Clinical decision support prompts at the time of order entry do improve the likelihood that practitioners will follow recommended practice. On a percentage basis, it still seems that about half of the time, the recommendations of clinical decision support are ignored or overruled. Sometimes this is due to the fact that the clinician has more information at his/her fingertips than the decision support system has. Sometimes the clinical support is not sufficiently detailed or complex to address real-life clinical situations. The trend of including clinical decision support in electronic health records is expanding, and with it, the likelihood that the decision support recommendations will be followed. As with many innovations, it takes time for systems to provide solid clinical information, and for practitioners to become accustomed to following best practice prompts.

David Schanding, M.A., M.M.