S0626 Implementation of an Acute GI Bleed Clinical Pathway in VA Hospital System

Abstract

INTRODUCTION: Physician order entry (POE) has been integrated into many electronic health records for years. Syracuse VA Medical Center (VAMC) has been using POE; however, clinical pathways are underused or lack implementation. We are implementing an acute GI bleed clinical pathway at the Syracuse VAMC. Our aim is to assess if this implementation will reduce time to place orders, reduce errors and omission of appropriate orders. METHODS: Acute GI bleed pathway was created in CPRS EMR based on evidence based practices and in collaboration with Hospitalist, Gastroenterology, and Radiology departments at the Syracuse VAMC. Upstate Medical University medicine residents were observed admitting a simulated patient with acute GI bleed with known liver cirrhosis with and without using pathway. Clinical scenario of the simulated patient was created by hospitalist physicians. A check list for required orders (total 15) were made. Total residents involved were 40 (10 PGY1, 2 PGY2 and 8 PGY3 for the pre-clinical pathway group; 12 PGY1, 4 PGY2 and 4 PGY3 for the post-clinical pathway group). Primary outcome was number of orders missed and secondary outcome was time spent to complete orders. RESULTS: In the pre-clinical pathway group; average number of orders missed were 5.7 and average time to place orders was 5.55 minutes. Most common orders missed were telemetry, spontaneous bacterial peritonitis (SBP) prophylaxis and liver function test. In the post-clinical pathway group; average number of orders missed were 1.15 and average time to place orders was 5.39 minutes. Most common orders missed were telemetry, SBP prophylaxis and GI consult. Acute GI bleed clinical pathway significantly reduced the number of orders missed (P = 0.0004). There was no significant alteration in time spent to complete orders in both groups. CONCLUSION: Clinical pathways are strongly recommended in EMR systems as they were proven to decrease error and improve standardization of patient care. Some studies of order sets for specific conditions have shown reduction in mortality, length of stay, and readmission. We found that using clinical pathway for acute GI bleed reduces omission of appropriate orders. The time physicians spent placing orders was not significantly affected by the clinical pathways. To note, common missed orders in both groups were telemetry and SBP prophylaxis which may be related to lack of medical knowledge. This study may be helpful to facilitate using clinical pathways for other medical conditions at VA hospitals.Figure 1.: Number of orders missed with and without using acute GI bleed clinical pathway.Figure 2.: Time spent to complete orders with and without using acute GI bleed clinical pathway.