Electronic Order Entry System Research Articles

Medication Prescribing Errors on a Surgery Service - Addressing the Gap with a Curriculum for Surgery Residents: A Prospective Observational Study.

Educational interventions with proven effectiveness to reduce medication prescribing errors are currently lacking. Our objective was to implement and assess the effectiveness of a curriculum to reduce medication prescribing errors on a surgery service. This was a prospective observational cohort study at a Canadian academic hospital without an electronic order entry system. A pharmacist-led medication prescribing curriculum for surgery residents was developed and implemented over 2 days (2 h/day) in July 2019. Thirteen (76%) out of 17 surgery residents contributed pre-implementation data, while 13 (81%) out of 16 surgery residents contributed post-implementation data. Medication prescribing errors were tracked for 12 months pre-implementation and 6 months post-implementation. Errors were classified as prescription writing (PW) or decision making (DM). There were a total of 1050 medication prescribing errors made in the pre-implementation period with 615 (59%) PW errors and 435 (41%) DM. There were a mean of 87.5 (SD = 14.6) total medication prescribing errors per month in the pre-implementation period with 51.3 (11.9) PW and 36.3 (6.0) DM errors. There were a total of 472 medication prescribing errors made in the post-implementation period with 260 (55%) PW and 212 (45%) DM errors. There were a mean of 78.7 (10.3) total medication prescribing errors per month in the post-implementation period with 43.3 (9.5) PW and 35.3 (4.2) DM errors. In the first quarter of the academic year, there were significantly fewer mean total errors per month post-implementation versus pre-implementation (77.7(12.7) versus 107.3(8.1); P = .035), with significantly fewer PW errors per month (40.7(13.2) versus 68.7(9.3); P = .046) and no difference in DM errors per month (37.0(2.0) versus 38.7(5.7);P = .671). There were no differences noted in the second quarter of the academic year. Medication prescribing errors occurred from PW and DM. Medication prescribing curriculum decreased PW errors; however, a continued education program is warranted as the effect diminished over time.

Identifying End Users' Preferences about Structuring Pharmacogenetic Test Orders in an Electronic Health Record System

Pharmacogenetics (PGx) testing can be used for detecting genetic variations that may affect an individual's anticipated metabolism of, or response to, medications. Although several studies have focused on developing tools for delivering results from PGx testing, there is a relative dearth of information about how to design provider-friendly electronic order-entry systems for PGx. The U.S. Department of Veterans Affairs (VA) is preparing to implement a new electronic health records system. In this study, VA PGx test end users were surveyed about their preferences for how electronic test orders for PGx should be structured, including the nomenclature that should be used to search for and identify PGx-test orders, whether to offer single- versus multigene tests, and whether information about test methodology should be included in the order name. Responses were analyzed systematically to identify areas of agreement and disagreement with the survey options, and areas where respondents' opinions diverged. End users endorsed preferences for flexible ways to identify and order PGx tests and multigene panel tests; opinions on whether test methodology should be included in the test name were divergent. The results could be used for both informing the VA's new electronic health records implementation (including how PGx tests are searched for and ordered) and for providing insights for other health systems implementing PGx-testing programs.

Rethinking the Drug Distribution and Medication Management Model: How a New York City Hospital Pharmacy Department Responded to COVID-19.

Beginning in March 2020, New York City began the fight against coronavirus disease 2019. Health care workers were faced with a disease that led to significant morbidity and mortality with no proven therapies. As hospitals became inundated with patients and underwent rapid expansion of capacity, resources such as drugs, protective and medical equipment, and hospital staff became limited. Pharmacists played a critical role in the management of clinical care and drug delivery during the pandemic. As members of the department of pharmacy within NewYork‐Presbyterian Hospital, we describe our experiences and processes to overcome challenges faced during the pandemic. Strict inventory management through the use of daily usage reports, frequent communication, and minimization of waste was critical for the management of drug shortages. The creation of guidelines, protocols, and restrictions were not only used to mitigate drug shortages, but also helped educate health care providers and guided medication use. Managing technology through setting up new automatic dispensing cabinets to address hospital expansions and modifying the electronic order entry system to include new protocols and drug shortage information were also vital. Additional key pharmacist functions included provision of investigational drug service support and training of pharmacists, prescribers, nurses, and respiratory therapists to educate and standardize medication use. Through implementation of operational and clinical processes, pharmacists managed critical drug inventory and guided patient treatment. As the pandemic continues, pharmacists will remain vital members of the multidisciplinary team dedicated to the fight against the virus.

A Redesigned Order Entry System for Reducing Low-Value Preprocedural Cardiology Consultations: Quality-Improvement Cohort Study.

BackgroundPreprocedural cardiac evaluation is a common reason for outpatient cardiology visits. Many patients who are referred to cardiology clinics for preprocedural evaluation are at low risk of perioperative events and do not require any further management. Our facility treats patients over a large geographic area; avoiding low-value consultations reduces time and travel burdens for patients.ObjectiveOur study objective was to assess the impact of a novel algorithm in the electronic order entry system aimed to guide clinicians toward patients who may benefit from cardiovascular referral.MethodsWe retrospectively reviewed in-person consultations and electronic consultations (e-consults) to our cardiology service before and after implementation of the novel algorithm to assess changes in patterns of care. Data were stored in a custom electronic database on internal servers.ResultsWe reviewed 603 consultations to our cardiology clinic and found that 89 (14.7%) were sent for preprocedural evaluation. Of these, 39 (43.8% of preprocedural consultations) were e-consults. After implementation, we reviewed 360 consultations. The proportion of consultations for preprocedural evaluation did not decrease (n=47, 13.0%; P=.39). We observed an absolute increase of 13.6% in the proportion of consultations ordered as e-consults (27/47, 57.4%). During the postintervention period, we received no remarks, concerns, or criticisms from ordering clinicians about the process change and no reports of adverse events.ConclusionsImplementation of an ordering algorithm to reduce low-value preprocedural cardiology evaluations did not lead to a reduction in the number of overall preprocedural cardiology consultations. The number of patients seen electronically increased, potentially improving clinic access and reducing travel burden for patients.

A follow-up audit of the completion of bone marrow specimen request forms at an academic laboratory

Background: In order to ensure that patients receive individualised treatment following bone marrow biopsy, it is necessary for clinicians to provide complete clinical information on bone marrow request forms (BMRFs). An audit of BMRFs six years previously showed poor completion, especially with regard to filling in full blood count results, transfusion history, medication history, information about the clinical examination and HIV status. This lead the laboratory to design a new bone marrow specimen request form. We did a follow-up audit to see if the new form had helped to improve the completion rates. Methods: We compared 400 forms to the 357 that were audited in 2013. The following details were recorded: date and time of collection, patient demographics, requesting doctor’s details, clinical information, current medication, transfusion history and HIV status, and details of the procedure completed by technologists, registrars and pathologists. Results: The 2019 follow-up audit showed significant improvements in the completion of the transfusion history, as well as the clinical examination and HIV status. Registrars and pathologists signed off forms regularly. The completion of patient demographic details, and requesting doctors’ names and telephone numbers worsened. Discussion and conclusion: We recommend that the form be simplified so the requesting doctors only need to tick yes or no, in a tick-box format, if a full blood count has been done in the preceding 24 hours. There needs to be a dedicated space for the hospital and laboratory stickers. Only the name and telephone number of one doctor should be requested. This doctor should preferably be the most senior doctor involved with patient care. All referring laboratories and hospitals will be consulted before updating the form. Unfortunately, it seems that the only way to force the completion of request forms is to introduce an electronic order entry system that does not accept incomplete forms.

1439. Reducing the Number of Urine Cultures Performed Through Stringent Urinalysis Reflex Criteria

BackgroundAlmost half of urine cultures (UCs) obtained are in asymptomatic patients, which may lead to misdiagnosis of urinary tract infection (UTI) and unnecessary treatment. To decrease misdiagnosis of UTI, changes were made to the order entry and urine culture process at our institution in April 2018. This included removal of a standalone UC from the electronic order entry system and development of a more stringent criterian for urinalysis with reflex culture (UAC). We evaluated the impact of these ordering changes on the total number of UCs performed.MethodsThis was a pre-post retrospective study comparing the hospital UAC rate per 1,000 patient-days and ED UAC rate per 1,000 visits in the pre-intervention period from April 2017 to March 2018 to the intervention period from May 2018 to March 2019 in a 319-bed teaching hospital in northwest Ohio. In April 2018, urine microscopy and UAC were the only available options. Furthermore, UC would only be performed if the following criteria were met: 10 white blood cells (WBC)/HFP. Standalone UC was available for the following patients who were excluded: immunosuppressed patients, pregnant women and patients undergoing invasive urologic procedures. These changes were accompanied by provider education, and providers were given the option to override UAC rules by calling the microbiology lab within 24 hours to request UC.ResultsAfter incorporating these changes, we observed an increase in the use of UAC compared with UC-only in both the ED (80% pre-vs. 94% post-implementation) and inpatient setting (59% pre-vs. 92% post-implementation). This was accompanied by a reduction in the overall UCs performed in both the ED (49.17 per 1,000 visits to 23.53 per 1,000 visits [P < 0.001]) and inpatient units (23.31 per 1,000 patient-days to 9.31 per 1,000 patient-days [P < 0.001]). Chart review of cases where providers overrode UAC criteria and requested UC have demonstrated no false negatives to date; cultures either had no growth or were consistent with contamination by polymicrobial urogenital flora.ConclusionRestricted access to standalone UC, implementation of UAC with more stringent criteria and provider education reduced the number of urine cultures performed without sacrificing sensitivity for detecting UTI and potential antimicrobial use.Disclosures All authors: No reported disclosures.

No refills: The durable impact of a multifaceted effort by surgical trainees to minimize the prescription of postoperative opioids

BackgroundSurgeons have the opportunity to help offset the opioid epidemic by leading with practice changes. We sought to decrease the amount of opioid prescribed postoperatively through a multifaceted program. MethodsA multipronged program was introduced in our hospital system, which included resident education on prescribing for postoperative analgesia, a change in the default number of opioid pills in an electronic medication order entry system, and the distribution of a guideline card of recommended postoperative opioid prescription amounts. The amount of opioid prescribed postoperatively between January 2016 and August 2018 was collected for the 10 most common short-stay (<48 hours) general surgery procedures. The 6 months prior to any intervention (pre-intervention) was compared to the last 6 months of data collection (post-intervention). ResultsIn the study, 14,007 operations were captured, including 2,530 pre-intervention and 2,715 post-intervention. The average amount of postoperative opioid prescribed in the pre-intervention period was 207.1 morphine milligram equivalents; post-interventions, the average amount declined to 104.6 morphine milligram equivalents (P < .01). The opioid refill rate remained the same (3.3% pre-intervention vs 3.1% post-intervention, P = .76). ConclusionA comprehensive program to eliminate the over-prescription of opioids decreased the amount of opioid prescribed by half, without a concurrent increase in opioid refills, demonstrating that simple measures can be used to deliver sustained and reproducible improvements in offering source control in the opioid epidemic.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment.

In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting. To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions. A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts. A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year. This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

Comparative usability evaluation of consultation order templates in a simulated primary care environment

Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = −0.05 [−0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.

Electronic alert system for improving appropriate thromboprophylaxis in hospitalized medical patients: a randomized controlled trial

Background The use of thromboprophylaxis among acutely ill hospitalized medical patients remains inconsistent. Objective To improve thromboprophylaxis use by implementing a computer-based alert system combined with a Geneva Risk Score calculation tool in the electronic patient chart and order entry system. Patients/Methods Consecutive patients admitted to the general internal medicine wards of the University Hospital Bern, Switzerland were randomized to the alert group, in which an alert and the Geneva Risk Score calculation tool was issued in the electronic patient chart, or to the control group, in which no alert was issued. The primary endpoint was the rate of appropriate thromboprophylaxis during hospital stay. Results Overall, 1593 patients (alert group, 804; control group, 789) were eligible for analysis. The median age was 67 years (interquartile range, 53-79 years) and 47% were female. Appropriate thromboprophylaxis was administered to 536 (66.7%) patients from the alert group and to 526 (66.7%) patients from the control group. Among the 804 patients from the alert group, a total of 446 (55.5%) either had no score calculation by the physician in charge (n = 348) or had a calculated score result that was inconsistent with information from the patient chart (n = 98). Appropriate thromboprophylaxis was less often administered to patients with no score or an inconsistent score result than to 358 patients with a consistent score result (62.6% versus 71.8%). Conclusions The electronic alert (e-alert) system did not improve appropriate thromboprophylaxis, most likely because many e-alerts were ignored by ordering physicians. The use of appropriate thromboprophylaxis in the control group was higher than expected.

Electronic Alert System for Improving Stroke Prevention Among Hospitalized Oral-Anticoagulation-Naïve Patients With Atrial Fibrillation: A Randomized Trial.

BackgroundMany patients with atrial fibrillation (AF) do not receive oral anticoagulants (OAC) for the prevention of stroke and systemic embolism. We aimed to improve the prescription of (OAC) among hospitalized patients with AF.Methods and ResultsWe developed a computer‐based electronic alert system for identifying hospitalized OAC‐naïve patients with AF. The alert system contained a CHA 2 DS 2‐VASc score calculation tool and provided recommendations for OAC prescription. The alert system was tested in a 1:1 randomized controlled trial at the University Hospital Bern: Patients with suspected AF without an active prescription order were allocated to an alert group in which an alert was issued in the electronic patient chart and order entry system or to a control group in which no alert was issued. The primary end point was the rate of adequate OAC prescription at hospital discharge, defined as prescription in OAC‐naïve men and women with CHA 2 DS 2‐VASc score ≥1 and ≥2, respectively. Overall, 889 OAC‐naïve patients (455 from the alert group and 434 from the control group) were eligible for analysis. Although the CHA 2 DS 2‐VASc score module was used in only 48 (10.5%) patients from the alert group, 100 (22.0%) patients from the alert group versus 69 (15.9%) from the control group received adequate OAC prescription (relative risk 1.38; P=0.021). OAC or antiplatelet therapy was prescribed in 325 (71.4%) patients from the alert group versus 271 (62.4%) from the control group (P=0.004).ConclusionsVersus standard care, the alert system modestly improved OAC prescription among consecutive hospitalized AF patients.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02455102.

Issue Highlights

Issue Highlights

Abstract 142: Design and Implementation of an Electronic Process for Provider-ordered Post-hospitalization Follow-up Appointment Scheduling for Inpatients in an Academic Cardiology Department

Introduction: Post-hospitalization outpatient follow-up visits are important components of high quality care for patients with cardiovascular diseases. However, challenges in scheduling appointments prevent many patients from obtaining timely post-discharge care. Hypothesis: We hypothesized that a streamlined process for follow-up appointment scheduling utilizing the electronic order entry system would be an effective means of scheduling post-discharge visits for many inpatient admissions. Methods: In effort to increase patient access to post-discharge care, we designed a process for electronic provider-ordered follow-up appointment scheduling that was implemented on cardiology inpatient services in a large academic medical center in January 2014. During a patient hospitalization, providers were given the capability to order a follow-up appointment via the electronic order entry system. The order allows providers to designate the time-frame for follow-up, desired outpatient providers, and patient scheduling preferences. These orders are electronically transmitted to appointment schedulers, who schedule visits within two hours of order entry six days per week. Appointment information is reviewed with patients prior to discharge. Results: During the first 12 months after implementation (January to December 2014), 3406 follow-up appointment orders were placed for 2749 patients, or 1.24 visits ordered per patient. At least one visit ordered for 49.8% of the total 5534 cardiology admissions. The percentage of admitted patients for whom an outpatient visit was ordered from the first through fourth three-month interval in 2014 significantly increased: 28.2%; 48.0%, 53.4%, and 63%, respectively (Figure, p&lt;0.0001). Conclusion: A post-hospitalization outpatient appointment scheduling process using the electronic order entry system can be an effective method for scheduling follow-up visits for many inpatients prior to discharge.

A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients With Cirrhosis.

Many hospitalized patients with cirrhosis are readmitted to the hospital within 30 days, particularly those with hepatic encephalopathy (HE). We performed a prospective study to assess the effects of a quality improvement protocol on readmission to a transplant center's liver unit within 30 days. We studied the effects of a quality improvement program in 824 unique patients with decompensated cirrhosis or receiving liver transplants (mean Model for End-Stage Liver Disease score, 17.7 ± 7.4) admitted to an inpatient hepatology unit from 2010 through 2013. The study had a year-long control period (626 admissions receiving usual care) and 2 intervention phases: a hand-held checklist phase (470 admissions) and an electronic phase that incorporated the checklist items into the electronic provider order entry system (624 admissions). The intervention phases included goal-directed lactulose therapy and rifaximin for overt HE, and prompts for antibiotic prophylaxis of spontaneous bacterial peritonitis. The primary endpoint was the difference in 30-day readmissions between the control and intervention phases. Trends in 30-day readmissions were compared with those of patients with decompensated cirrhosis admitted at another center. During the electronic phase, study subjects had 40% lower adjusted odds of 30-day readmission than during the control period. The slope of the decline in readmissions over time was significantly greater than for patients at the other center (P < .0001). The proportion of patients with greater than grade 2 HE and 30-day readmission was 48.9% (66 of 135) in the control period versus 26.0% (27 of 104) in the electronic phase (P = .0003). Treatment of HE with rifaximin and secondary prophylaxis of spontaneous bacterial peritonitis with antibiotics (on discharge) were associated with lower adjusted odds of readmission (odds ratios, 0.39 and 0.40, respectively). The electronic phase was associated with 1.34 fewer hospital days for HE compared with the control period (P = .01). In a prospective study, a quality improvement initiative that included electronic decision support reduced readmissions of patients with cirrhosis to the hospital within 30 days.

Leveraging Clinical Informatics in the Conduct of Clinical Trials.

Randomized clinical trials play an important role in the advancement of science, pursuit of improved health, and quest for more effective delivery of health care. Patients, policy makers, and the medical community recognize these trials as the gold standard in the development of evidence on which to base the delivery of medical care [1]. In spite of their importance, the conduct of these trials is challenging for a variety of reasons, including their cost and complexity to perform [2]. The field of applied clinical informatics is increasingly wellpositioned to facilitate many of the traditional steps required for the successful conduct of a prospective randomized clinical trial, potentially catalyzing the efficient generation of highquality medical evidence and incorporation of the medical record into a learning health system [3, 4]. Most randomized clinical trials follow a relatively set sequence of six steps. A population of patients is screened for eligibility by study inclusion and exclusion criteria. Those patients who meet criteria are considered for enrollment in the trial. Enrolled patients are randomized into study groups (i.e., control vs. intervention(s)). The assigned intervention is delivered and the rate of receipt of study intervention is recorded. Data are collected about patients’ response to the intervention over the course of the trial and outcomes at the end of the trial are measured. Data are synthesized and analyzed to allow interpretation of the results of the trial. Now more than ever, there is burgeoning potential for clinical informatics to facilitate each of these steps. BSniffing^ applications can automatically screen populations of patients for eligibility, by comparing defined inclusion and exclusion criteria with data housed in an electronic medical record [5]. These applications can then be used to flag potential study participants [6]. Once patients are enrolled in a study, randomization assignment can be automatically generated using a real-time randomization scheme built into a study application. Delivery of the assigned intervention can also be facilitated by informatics (e.g., an advisor in the computerized provider electronic order (CPOE) entry system that directs providers to an assigned medication, or an automatic generation of an order to pharmacy, laboratory, etc.) [7] or the informatics applications themselves may be the study intervention (e.g., a clinical decision support system to aid providers in the management of a clinical condition) [8, 9]. Through the automated collection of clinical data from existing sources which make up the larger electronic medical record (e.g., CPOE, pharmacy logs, clinical monitoring systems, laboratory systems, billing systems, registration systems), informatics can provide information regarding compliance with the assigned study intervention (e.g., dispensing of assignedmedication by pharmacy, administration by bedside nurse), changes over time in response to the intervention (e.g., changes in physiologic measures and laboratory values over the course of the study), and trial outcomes (e.g., death, hospital length of stay, development of organ dysfunction). Although these data are typically collected in raw form and then analyzed at defined time points in a study, informatics can also help synthesize, analyze, and present the data in real-time to facilitate monitoring and conduct of the study. (e.g., dashboards for study personnel detailing enrollment, compliance, and safety measures or interim analyses in Bayesian design studies). * Jesse M. Ehrenfeld jesse.ehrenfeld@Vanderbilt.Edu

Cardiology and accountable care.

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …

Risk infection to spare bleeding? The quandary of splenectomy for immune thrombocytopenia.

Risk infection to spare bleeding? The quandary of splenectomy for immune thrombocytopenia.

Clinician perspectives on considering radiation exposure to patients when ordering imaging tests: a qualitative study

Background and objectivesIncreased computer tomography (CT) scan use has contributed to a rise in medically-associated radiation exposure. The extent to which clinicians consider radiation exposure when ordering imaging tests is...

Emergency Physician Variation in Admissions for Common Chief Complaints

The emergency department (ED) represents an increasing source of hospital admissions, placing costly decisions in the hands of emergency physicians. Emergency physicians have been shown to vary dramatically in their admission rates, suggesting some providers may admit patients unnecessarily. It is unclear whether this variation in provider admission rates exists across all types of patient presentations. Determining the degree of admission rate variation for common chief complaints may help delineate clinical presentations that increase risk of inappropriate and costly hospital admissions. This retrospective study examined board certified/eligible emergency physicians practicing at an 850-bed tertiary level 1 trauma center with 85,000 annual care visits. Physicians worked equally in all areas of the ED. Patient characteristics and encounter data were obtained from an electronic medical record and physician order entry system from August 2008 to January 2012. Urgent care visits, patients younger than age 8, and trauma activations were excluded. Physicians were excluded if they worked less than 200 clinical hours, had less than 50 observations of a given chief complaint, or worked primarily in the pediatric ED. Admission rates were modeled using Emergency Severity Index, patient age, and time of presentation with logistic regression to adjust for differences in patient populations between physicians. Adjusted admission rates were modeled for the chief complaints of abdominal pain, shortness of breath, chest pain, and headache. Odds ratios were calculated to determine whether physicians with high admission rates (upper quartile) were consistent across chief complaints. There were 193,532 eligible ED visits, 57,213 of which resulted in admission. There were 48 emergency physicians who averaged 2,494 clinical hours and saw 3,949 patients during the study period. Each physician admitted an average of 1,168 patients. The adjusted overall admission rate was 23.5% (95%CI 22.9-24.3%) of ED visits, ranging from 17.4% (95%CI 16.2-18.6%) to 33.5% (95%CI 32.3-34.8%). The upper quartile of providers ordered 87% of admissions above the group average. There was large variation in admission rates between providers for all chief complaints. Shortness of breath had the highest admission rate among chief complaints, with 36.8% (range 17.1-53.0%) of visits resulting in admission. This was followed by abdominal pain (29.2%, 16.2-41.2%), chest pain (24.9%, 11.8-38.4%), and headache (15.3%, 5.4-26.7%). The odds ratio that high admitters for chest pain were high admitters for all patients was 34.0 (95%CI 5.84-197.8). High admission rates for shortness of breath (12.8, 95%CI 2.78-58.9) and abdominal pain (8.96, 95%CI 2.03-39.6) also predicted high overall admission rates. Odds ratios show high admitters of any one chief complaint were consistently high admitters for any one other chief complaint except headache. Large variation exists in provider admission rates for common chief complaints. A small group of providers appears to account for a significant volume of excess admissions in all chief complaints. Common factors may exist in this group that guide admission decisions. Chest pain and shortness of breath demonstrated the most variation among providers and appear to be good targets for interventions aimed at reducing unnecessary admissions.

Current situation for medication process and pharmacovigilance in The Netherlands: a comparison between cytostatic and non-cytostatic agents

AimTo describe the current situation regarding the medication order entry system and pharmacovigilance for cytostatic and non-cytostatic agents in The Netherlands.MethodAn electronic questionnaire, consisting of multiple choice questions, was sent...