Electronic Order-set as a Quality Improvement Initiative to Optimize Management of Hospitalized Inflammatory Bowel Disease Patients

Abstract

Introduction: Although there are various recommendations regarding inpatient management of Inflammatory Bowel Disease (IBD), a unified and guideline-driven protocol is lacking within our institution at Boston Medical Center. The creation of a tailored IBD order-set as a Quality Improvement (QI) initiative may further optimize care of these patients. The utility of repeat C. difficile testing in this setting also remains unclear. Provider habits were assessed through institutional metrics data and a house staff survey, including use of Venothromboembolism (VTE) prophylaxis and C. difficile testing. Methods: A 9-point questionnaire was administered among 154 Internal Medicine residents to assess confidence in the following areas of inpatient IBD care: VTE prophylaxis, C. difficile PCR testing, imaging and initiating antibiotics or steroids. A clinical data warehouse inquiry using ICD10 (or equivalent ICD9) codes for Ulcerative Colitis or Crohn's Disease abstracted rates of VTE prophylaxis (heparin or enoxaparin) and C. difficile testing in IBD patients hospitalized between 3/1/16-3/1/17. Results: A total of 216 patients with IBD were admitted to the surgical or medical service for any cause during this period. Heparin or enoxaparin was ordered in 168 patients (77%) during the hospital course and 72 (25%) had C. difficile testing. The survey response rate was 26.6% (41 residents) and reveals the average likelihood of ordering heparin or enoxaparin in an IBD patient admitted with gastrointestinal bleeding is only 52% (Figure 1). Only 46.3% of residents would reorder C. difficile PCR in symptomatic patients with negative results 4 weeks prior (Figure 2). 24.4% were “not confident at all” ordering medications and 65.6% view favorably the prospect of an IBD order-set to increase efficiency and consistency.Figure: House Staff survey results demonstrating variation in provider likelihood of ordering VTE prophylaxis with either heparin or enoxaparin in a hospitalized IBD patient presenting with gastrointestinal bleeding.Figure: Percentage of respondents who would perform repeat C. difficile testing at various time thresholds of negative prior testing. Participants were asked to “choose all that apply”.Conclusion: Findings at our institution highlight variation in provider confidence and knowledge in the inpatient care of IBD patients. In conjunction with clinical judgment, we anticipate this order-set will guide the residents in making appropriate medical decisions. It is expected that this tool will facilitate more efficient and comprehensive care of this complex patient population, thereby optimizing long-term outcomes. An IRB-approved chart review is underway as a QI post-implementation strategy to assess the effectiveness of the order-set in the care of hospitalized IBD patients. Continued assessment of provider actions for C. difficile re-testing and resultant patient outcomes are also of interest.