Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: a Quasi-Experimental Study

Abstract

BackgroundInpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic medical record (EMR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians towards best clinical practices. Our objective was to utilize CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net healthcare system. MethodsOur first intervention involved enhancing an existing order set for phosphate repletion by incorporating CDS to guide appropriate repletion orders based on deficit severity and simplifying ordering. The second intervention was a best practice advisory (BPA) that triggered when an intravenous (IV) phosphate repletion was ordered for a patient with mild to moderate phosphate deficiency without an existing nil per os (NPO) order. The primary outcome measure was the number of patients with mild and moderate hypophosphatemia receiving IV replacement without NPO orders per 1000 patient days. ResultsAcross all hospitals, rate of IV replacement in patients with mild to moderate hypophosphatemia (1.0 to 1.9 mg/dL) without NPO orders decreased from 7.22 to 3.40 per 1000 patient days (53.0% reduction, p<0.001), while the oral replacements in this population increased from 6.39 to 8.87 (38.8% increase, p<0.001). For patients with phosphate levels ≥2.0, IV replacements decreased from 10.66 to 5.36 (49.8% reduction, p<0.001) and oral replacements decreased 19.78 to 16.69 (15.6% reduction, p<0.01). ConclusionsOur intervention successfully reduced inpatient IV phosphate replacements by 53% in patients with mild to moderate hypophosphatemia using a two-pronged electronic health record intervention across a large safety net setting.