Order Set Implementation Research Articles

Reduction in Lidocaine Dose Administration for Flexible Bronchoscopy Following Order Set Implementation

Reduction in Lidocaine Dose Administration for Flexible Bronchoscopy Following Order Set Implementation

Specific Physician Orders Improve Pain Detection and Pain Reports in Nursing Home Residents: Preliminary Data

Despite evidence that many nursing home residents' pain is poorly managed, reasons for this poor management remain unanswered. The aim of this study was to determine if specific order sets related to pain assessment would improve pain management in nursing home (NH) residents. Outcomes included observed nurse pain assessment queries and resident reports of pain. The pretest/post-test study was performed in a 240-bed for-profit nursing home in the mid-southern region of the United States and participants were 43 nursing home residents capable of self-consent. Medical chart abstraction was performed during a 2-week (14-day) period before the implementation of specific order sets for pain assessment (intervention) and a 2-week (14-day) period after the intervention. Trained research assistants observed medication administration passes and performed participant interviews after each medication pass. One month after intervention implementation, 1 additional day of observations was conducted to determine data reliability. Nurses were observed to ask residents about pain more frequently, and nurses continued to ask about pain at higher rates 1 month after the intervention was discontinued. The proportion of residents who reported pain also significantly increased in response to increased nurse queries (e.g., “Do you have any pain right now?”), which underscores the importance of nurses directly asking residents about pain. Notably 70% of this long-stay NH population only told the nurses about their pain symptoms when asked directly. Findings uncover that using specific pain order sets seems to improve the detection of pain, which should be a routine part of nursing assessment.

Effectiveness of Inpatient Insulin Order Sets Using Human Insulins in Noncritically Ill Patients in A Rural Hospital

Recent guidelines recommend a physiologic approach to non-intensive care unit (ICU) inpatient glucose management utilizing basal-bolus with correctional (BBC) insulin over traditional sliding-scale insulin monotherapy. Unfortunately, few studies exist using a BBC approach restricted to human insulins (regular and neutral protamine Hagedorn [NPH]). This study evaluated changes in provider prescribing patterns, effects on blood glucose, and safety with implementation of hospital order sets for BBC using human insulins. Order sets were developed for non-ICU inpatients, consisting of basal, prandial, and correctional insulin using NPH and regular human insulins. Evaluation compared a 4-month period before (admissions, n = 274) with a 4-month period after order set availability (n = 302). Primary outcome was change in insulin prescribing patterns. Secondary outcomes included use of nonpreferred diabetes treatments, hemoglobin A1c testing, mean daily blood glucose, and incidence of hypoglycemia. Use of BBC insulin regimen increased from 10.6 to 27.5% after order set implementation (P<.001). Use of oral antihyperglycemic agents decreased from 24.1 to 14.9% after implementation (P = .006). Hemoglobin A1c testing rose from 50.0 to 62.3% after (P = .003). Mean daily blood glucose improved, with an estimated mean difference of 14.4 mg/dL (95% confidence interval, 2.2 to 26.5 mg/dL) over hospital days 3 through 9 (P = .02). There was no significant change in the incidence of moderate or severe hypoglycemia. Implementation of hospital-wide human insulin order sets led to improvements in prescribing practices and blood glucose control, without increasing the incidence of hypoglycemia. These order sets may be useful for facilities limited by formulary and cost considerations to the use of older human insulins.

Gaps in the inpatient management of chronic obstructive pulmonary disease exacerbation and impact of an evidence-based order set.

Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions. To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD. The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario. A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5 ± 7.7 days before order sets to 4.1 ± 5.0 days with order sets (P=0.017). Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.

An Analysis of VTE Prophylaxis Practice in Oncology Patients after Implementation of a Standardized Mandatory Computerized Clinical Decision Support Tool

▪Introduction: Venous thromboembolism (VTE) is an important cause of morbidity and mortality in oncology patients. Prophylaxis reduces the risk of VTE by 60% but many patients are not prescribed risk-appropriate VTE prophylaxis. We developed mandatory computerized clinical decision support-enabled, service-specific (CCDS) order sets to improve our institution’s VTE prophylaxis performance. The order sets require providers to complete short check lists to assess VTE risk factors and contraindications to pharmacologic prophylaxis. Based upon the answers to these questions, the order sets display the risk-appropriate VTE prophylaxis regimen for each individual patient. The purpose of this retrospective study is to evaluate VTE prophylaxis and events rates in hospitalized cancer patients admitted using a CCDS medical oncology VTE order set.Methods: Using electronic administrative records, we retrospectively collected prescription and clinical data on patients admitted to the solid tumor and hematologic malignancy services at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center (JHSKCCC) from October 17, 2010 (date of order set implementation) through June 30, 2014. A two-sided student’s t test or chi-square test were used for statistical analyses, as appropriate.Results: 7920 patients were admitted from 10/17/2010 to 6/30/14. The mean age was 57 years and 46% were female. The median length of stay was 4 days. Solid tumor service providers were more likely to prescribe risk-appropriate VTE prophylaxis (Table 1) and patients on the solid tumor service were more likely to be assessed as being at high risk for VTE (Table 2). Pharmacologic prophylaxis was more common on the solid tumor service while ambulation was the most common form of prophylaxis on the hematologic malignancy service. (Table 3) Risk-appropriate VTE prophylaxis was high on both services (Figure 1). Data on objectively-confirmed hospital-acquired VTE will be presented at the meeting.Conclusion: We report the largest analysis to date of VTE prophylaxis practices in hospitalized cancer patients. Significant differences in perceived VTE risk and prescribed prophylaxis were noted between services. Use of a computerized decision support-enabled VTE prophylaxis order set was associated with high rates of risk-appropriate VTE prophylaxis.Table 1:Patient Population CharacteristicsSolid TumorHeme MalignancyP-ValueTotal – no.49952925Mean Age – no. (SD)58.0 (13.2)56.1 (14.7)<0.001Female – no.2290 (46%)1303 (45%)Median length of stay (IQR)4 (3-6)5 (3-10.5)Risk Appropriate Prophylaxis4410 (88%)2474 (85%)<0.001Table 2:VTE Risk Assessment of Patient PopulationVTE Risk CategorySolid TumorHeme MalignancyP-valueHigh Risk – no. (%)4782 (96%)2338 (80%)<0.001High Risk w/ CI –no. (%)1222 (25%)1789 (61%)<0.001High Risk w/o CI - no. (%)3560 (71%)549 (19%)<0.001Moderate Risk – no. (%)213 (4%)587 (20%)<0.001Mod. Risk w/ CI – no. (%)41 (1%)506 (17%)<0.001Mod. Risk w/o CI – no. (%)172 (3%)81 (3%)<0.001CI= Contraindication to pharmacologic prophylaxisTable 3:VTE Prophylaxis OrdersMedical OncologyHeme MalignancyP-valuePharm Only – no. (%)2992 (69%)412 (15%)<0.001Mech Only – no. (%)700 (16%)563 (20%)Pharm + Mech – no. (%)388 (9%)87 (3%)Ambulation Only – no. (%)230 (5%)1699 (61%)<0.001Pharm= pharmacologic prophylaxis (i.e. unfractionated or low molecular weight heparin, fondaparinux), Mech= graduate compression stockings or sequential compression devices or both [Display omitted] DisclosuresStreiff:Boehringer-Ingelheim: Consultancy; Daiichi-Sankyo: Consultancy; Janssen Healthcare: Consultancy; Pfizer: Consultancy; Portola: Research Funding.

Assessing Compliance With Established Pneumonia Core Measures at a Comprehensive Cancer Center.

Healthcare organizations use Pneumonia Core Measures (PCMs) to ensure delivery of high-quality care. In this study, a multidisciplinary team was organized to optimize care and enhance compliance in a comprehensive cancer emergency center. We performed a four-phase study, three of which were interventional: intense education regarding PCM; microbiologic analysis of the pathogens responsible for the pneumonias; development and implementation of an institutional pneumonia algorithm and order set. In phase 4, we analyzed five PCMs. The percentage of pneumonia patients from whom blood cultures were obtained increased from 73% to 91% after intervention (p < .001); sputum cultures increased from baseline 24.6% to 51% (p = .004) post order-set implementation, and order-set utilization increased from 40% to 77%. We achieved the benchmark for only one PCM, PN 3a. More than 80% of patients met clinical and microbiological criteria for healthcare-associated pneumonia. We identified a gap between our patient population and some PCMs that relates to antibiotics selection. The treatment of cancer patients and pneumonia falls outside established guidelines for treating community-acquired pneumonia. Although the algorithm and order set implemented optimized care and minimized variation, national benchmarks for four of the PCMs were not met. Our findings provide information for policymakers considering pneumonia measurements for antibiotic selection in a cancer care setting.

A Multifaceted Intervention for Patients With Anaphylaxis Increases Epinephrine Use in Adult Emergency Department

Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence. A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated. The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit. Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

Abstract T P252: Improving Quality of Care and Outcomes in the Community Through the Inclusive Collaboration Between a Certified Comprehensive Stroke Center and Regional Hospitals

Background: and Issues As a certified Comprehensive Stroke Center (CSC) it is our obligation to the community and regional hospitals to improve the quality of care and stroke patient outcomes. The spokes are interdependent components of our CSC program; they seek a shared value in improving the delivery of stroke care in their community. Many areas utilize telemedicine without an inclusive operational model to deliver care. Our approach to advance stroke care was to cultivate relationships between staff, physicians, Emergency Medical System (EMS) personnel and hospital administrators. Purpose: Construct a stroke care model, utilizing an inclusive collaborative team that consists of EMS, spoke hospitals, and regional communities. Methods: W. Edwards Deming’s and John A Woods’s work served as the framework for our stroke and telemedicine programs. Leaders must function with an attitude of inclusiveness, resulting in no subordinates or superiors within the multidisciplinary team. Breaking down barriers and building a shared vision in the delivery of stroke care and recognizing that each department serves the other results in shared objectives. Utilizing tele-health cloud software enhances clinical collaborations. Elimination of fear creates an environment of no-blame, permitting everyone to work at their highest potential through approachable leadership. Analyzing each step and the resultant effect involves an in-depth evaluation of processes with implementable solutions and training and education. Results: Results of this inclusive collaboration included: an 85% increase in administration of tissue plasminogen activator at the spoke hospitals; EMS education of over 2000 personnel; physician-driven quarterly spoke hospital case study reviews; implementation of standardized stroke order sets and algorithms; and four spoke hospitals awarded primary stroke certification and state designation. Conclusions: Through an inclusive quality culture and a passionate stroke team, improving regional stroke care is achievable and sustainable. A reliable cloud-based network plays a role, but leadership in collaboration with the regional entities is the strength of the program.

The effect of patient care order sets on medical resident education: a prospective before-after study

BackgroundPatient care order sets are increasingly being used to optimize care. While studies have evaluated the impact of order sets on provider performance and patient outcomes, their impact on postgraduate medical trainee knowledge remains unknown. We sought to evaluate the impact of order sets on respirology knowledge, order-writing skills, and self-reported learning.MethodsWe conducted a prospective before-after study. Postgraduate trainees completing a Respirology rotation at a quaternary-care hospital 6 months before (no order set period) and 12 months after (order set period) order set introduction. Guideline-based admission order sets with educational prompts detailing recommended management of cystic fibrosis and chronic obstructive pulmonary disease were implemented on the respirology ward. Each resident completed a test before and after the rotation assessing knowledge and order-writing. Residents in the order set period additionally completed a questionnaire regarding the impact of order set use on their learning. Analysis: The primary outcome, the difference between pre and post rotation scores was compared between residents in the no order set period and residents in the order set period, using univariate linear regression. Test validity was assessed with a 2-sample t-test, analysis of variance and Pearson’s correlation coefficient. Self-reported impact of order set use were descriptively analyzed, and written responses were collated and coded.ResultsInvestigators consecutively recruited 11 subjects before and 28 subjects after order set implementation. Residents in the order set period had a greater improvement in post-rotation test scores than residents in the no order set period (p = 0.04); after adjustment for baseline scores, this was not significant (p = 0.3). The questionnaire demonstrated excellent convergent, discriminant and construct validity. Residents reported that order sets improved their knowledge and skills and provided a systematic approach to care.ConclusionsOrder sets do not appear to impair resident education, and may impart a benefit. This will require validation in larger studies and across diseases.

The New Brunswick Comprehensive Diabetes Strategy—Redefining Provincial Diabetes Care from the Ground Up

The New Brunswick Diabetes Strategy was endorsed in June 2011. This 4-year strategy is based on the chronic care framework and integrates a wide array of actions within the health and community sector with the goal of improving “everyday pathways” for patients and providers. The strategy encompasses a variety of actions to target improved levels of A1C, LDL, blood pressure and foot care. A diabetes registry was created allowing fee for service primary care providers to receive a personalized profile of all the patients with diabetes in their practice and each patients latest A1C and LDL result as well as cumulative data on the average A1C and LDL in their patient population compared to those of their peers in the same geographical zone. Providers also receive a bright “pink sheet” in their lab reports anytime a patient has an A1C >7%, which lists the cumulative 5-year A1C’s for that individual. Diabetes case managers have been hired to rotate through family practices to focus on patients with A1C’s >8% and community health coaches work with patients on goal setting and follow through. Facilitation of province-wide implementation of hospital insulin order sets has been initiated to optimize inpatient diabetes care. A clinical innovation fund provides seed money to deserving hospital and community projects. Key features of this strategy include the affordability and sustainability of action areas with the goal of effective system change.

The Utilization of Standardized Order Sets Using AASLD Guidelines for Patients With Suspected Cirrhosis and Acute Gastrointestinal Bleeding

To improve the adherence to AASLD (American Association for the Study of Liver Diseases) guidelines for variceal bleeding, we developed and implemented standardized order sets for gastrointestinal bleeding in our hospital on October 1, 2009. We performed medical record reviews of hospitalized patients with gastrointestinal bleeding with suspected cirrhosis from October 2009 to October 2010 to determine the use of octreotide, prophylactic antibiotics, and endoscopy. We reviewed 300 Medical records and identified 26 patients with suspected cirrhosis and gastrointestinal bleeding who had adequate information to determine whether or not the order set was used. Antibiotic was used in 76% of patients, octreotide was used in 76% of patients, and upper endoscopy was completed in 94% of patients within 24 hours. The use of antibiotics was higher than that used in historical controls in our hospital. Implementation of standardized order sets appears to have improved adherence to standard recommendations. However, larger studies with longer follow-ups are needed to evaluate this effect on clinical outcomes and cost of care.

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Introduction: Safe and effective glycemic control in the intensive care unit (ICU) is a labor intensive and challenging process. Many modalities of glucose management have been implemented to attain glycemic targets including sliding scale insulin, subcutaneous basal insulin, and insulin infusions. One of the major challenges with targeted glycemic control utilizing insulin infusions has been hypoglycemia. A new ICU insulin infusion order set was created to eliminate calculation errors, minimize user error, incorporate nutritional intake, and improve safety. Hypothesis: Implementation of a modernized continuous insulin infusion order set will reduce insulin infusion-related hypoglycemia Methods: This study incorporates a before-after study design. A baseline analysis of insulin infusion-related hypoglycemia rates was conducted in June 2011. The new insulin infusion order set was implemented in September 2011 with extensive nursing education. The retrospective analysis of safety and efficacy was conducted one month after order set implementation. It was estimated that 21 patients in each cohort would be required to achieve 80% power to determine a 25% reduction in hypoglycemia with the level of significance of 0.05. Results: A total of 47 patients with 2588 blood glucose readings and 35 patients with 1250 blood glucose readings were evaluated in June and October 2011, respectively. There was a significant reduction in percentage of hypoglycemic readings (blood glucose < 70 mg/dL) from 1.9% to 0.3%. Percent of patients with at least one hypoglycemic reading was significantly reduced from 48.9% to 5.7%. Percentage of patient days with at least one hypoglycemic reading was also significantly reduced from 16.5% to 3.6%. No significant difference in severe hypoglycemia (blood glucose < 40 mg/dL) was seen. There was a 23% increase in the percentage of readings within the desired glucose goal range with the new order set as well as a 14% reduction in the percentage of readings above the desired goal range. Conclusions: Significant improvements in insulin infusion-related hypoglycemia rates are possible when incorporating defined infusion rates, nutritional intake, and after targeted nursing educational in-services.

Use of order sets in inpatient computerized provider order entry systems: A comparative analysis of usage patterns at seven sites

BackgroundMany computerized provider order entry (CPOE) systems include the ability to create electronic order sets: collections of clinically related orders grouped by purpose. Order sets promise to make CPOE systems more efficient, improve care quality and increase adherence to evidence-based guidelines. However, the development and implementation of order sets can be expensive and time-consuming and limited literature exists about their utilization. MethodsBased on analysis of order set usage logs from a diverse purposive sample of seven sites with commercially and internally developed inpatient CPOE systems, we developed an original order set classification system. Order sets were categorized across seven non-mutually exclusive axes: admission/discharge/transfer (ADT), perioperative, condition-specific, task-specific, service-specific, convenience, and personal. In addition, 731 unique subtypes were identified within five axes: four in ADT (S=4), three in perioperative, 144 in condition-specific, 513 in task-specific, and 67 in service-specific. ResultsOrder sets (n=1914) were used a total of 676,142 times at the participating sites during a one-year period. ADT and perioperative order sets accounted for 27.6% and 24.2% of usage respectively. Peripartum/labor, chest pain/acute coronary syndrome/myocardial infarction and diabetes order sets accounted for 51.6% of condition-specific usage. Insulin, angiography/angioplasty and arthroplasty order sets accounted for 19.4% of task-specific usage. Emergency/trauma, obstetrics/gynecology/labor delivery and anesthesia accounted for 32.4% of service-specific usage. Overall, the top 20% of order sets accounted for 90.1% of all usage. Additional salient patterns are identified and described. ConclusionWe observed recurrent patterns in order set usage across multiple sites as well as meaningful variations between sites. Vendors and institutional developers should identify high-value order set types through concrete data analysis in order to optimize the resources devoted to development and implementation.

Improving Venous Thromboembolism Prevention Processes and Outcomes at a Community Hospital

Venous thromboembolism (VTE) is a cause of significant morbidity and mortality in hospitalized patients in the United States. Quality improvement (QI) strategies to increase the rates of prophylaxis in patients at-risk for VTE have been shown to be successful. The development of a formal, active strategy addressing the prevention of VTE, as a written, institutionwide VTE prophylaxis policy, presents a challenge for hospitals In 2007 a multidisciplinary VTE committee was initiated to develop and implement a hospitalwide QI program to standardize VTE risk assessment and prophylaxis prescribing practices at Saint Francis Hospital (Tulsa, Oklahoma). The QI program included clinician education, VTE order set and electronic trigger implementation, and changes in mechanical prophylaxis usage. The VTE prophylaxis order set was successfully piloted and implemented hospitalwide within three months of the project's initiation. Standardization of VTE prophylaxis practices across surgical and medical specialties was the key aim of this QI program. As a result, patient-related outcomes were also improved. The number of hospital-acquired VTE events decreased from 123 (0.39%) in 2008 to 99 (0.32%) in 2009 and 87 (0.27%) in 2010, and a reduction in the VTE rate between 2008 and 2010 of 31.6%. There was a significant decrease between 2008 and 2010 in the number of hospital-acquired VTE events (p = .035). Keys to the success of this QI program included leveraging multidisciplinary VTE committee members, physician champions, multiple approaches to communication and education, and providing evidence to support the changes. Sharing the hospital's QI process may provide a model for other hospitals challenged with developing and sustaining positive outcomes in patients at risk for VTE.

Evidence-based Venous Thromboembolism Prophylaxis is Associated With a Six-fold Decrease in Numbers of Symptomatic Venous Thromboembolisms in Rehabilitation Inpatients

To measure the impact of a standardized risk assessment tool and specialty-specific, risk-adjusted venous thromboembolism (VTE) order sets on compliance with American College of Chest Physicians (ACCP) guidelines and the number of symptomatic VTE as assessed by administrative data. Prospective cohort study. Academic hospital inpatient rehabilitation unit. All patients on the rehabilitation unit. Assessment of VTE risk factors and evaluated admission VTE prophylaxis orders before and after implementation of an ACCP guideline-based, specialty-specific VTE risk assessment, and prophylaxis order set by using a standardized data collection form. Discharge diagnostic codes for VTE and pulmonary embolism were tracked by ICD-9 (International Classification of Diseases, 9th edition) discharge diagnosis codes for the 12 months before and 36 months after the intervention. Before implementation of the VTE order set, 27% of patients received VTE prophylaxis in compliance with the 2004 ACCP VTE guidelines. By following implementation of specialty-specific, risk-adjusted VTE order sets, compliance increased to 98%. In the year before VTE order-set implementation, the number of VTEs per admission was 49 per 1000. By following implementation, the number of VTEs steadily decreased each year to 8 per 1000 in 2007 (χ(2) = 14.985; P = .0001). Implementation of a standardized VTE risk assessment tool and prophylaxis order set resulted in a substantial improvement in compliance with ACCP guidelines for VTE prophylaxis and was associated with a 6-fold reduction in the number of symptomatic VTEs in a hospital-based rehabilitation unit.

Impact of a Venous Thromboembolism Prophylaxis “Smart Orderset”: Improved Compliance, Fewer Events

Abstract 172▪FN2▪This icon denotes a clinically relevant abstract Introduction:Venous Thromboembolism affects 900,000 Americans annually. Prophylaxis reduces the risk of VTE by 60% but many patients do not receive risk-appropriate VTE prophylaxis. We developed mandatory computer decision support “smart ordersets” (i.e. electronic menus with DVT prophylaxis recommendations) to improve our institution's VTE prophylaxis performance. The ordersets require providers to respond to 2 questions that assess VTE risk factors and contraindications to pharmacologic prophylaxis. Using these answers along with known patient demographics, the orderset gives providers an evidence-based risk-appropriate VTE prophylaxis recommendation. Methods:To study the impact of Medicine service-specific orderset on compliance with the 2008 American College of Chest Physicians (ACCP) VTE prophylaxis guideline and clinical outcomes, we conducted a retrospective cohort chart review of consecutive patients admitted to the Medicine service during one month immediately prior to (November 2007) and a single month subsequent to (April 2010) orderset launch. Data collection included patient demographics, VTE risk factors, and use and type of VTE prophylaxis. Patient characteristics before and after implementation of the protocol were compared. The primary outcome measures were compliance with thromboprophylaxis guidelines in patients at risk for VTE and the 90-day VTE rate. Secondary outcomes were bleeding events and 30-day mortality. Outcomes were compared by Student's t-test and Fisher's exact test. Results:The before and after cohorts contained 1,025 and 1,057 patients, respectively. Demographic characteristics and contraindications to pharmacologic prophylaxis were similar between groups. (Table 1) Some VTE risk factors were more prevalent in the before group. (Table 1) ACCP compliant prophylaxis increased significantly from 68.3% to 85.9% (p <.0001). Provider choices for prophylaxis changed with an increase in mechanical prophylaxis and twice daily heparin in the post-orderset implementation cohort. (Table 2) Radiographically-documented symptomatic VTE by day 90 post-hospital discharge declined from 2.8% to 0.7% after orderset implementation (p=0.001). There was also a trend toward fewer in-hospital VTE (0.8% versus 0.2%, p=0.06). (Figure 1) Major bleeding remained unchanged (0.3% to 0.1%, p=0.47).Table 1Patient CharacteristicsPatient CharacteristicsPre-Orderset (n = 1,025)Post-Orderset (n = 1,057)p-valueMean Duration of Hospital Stay ± S.D., days5.10 ± 6.354.65 ± 5.190.09Mean Age ± S.D. yr55.9 ± 17.055.0 ± 16.50.19Male Sex — no. (%)516 (50.3)549 (51.9)0.47Race/Ethnicity — no. (%)0.88White391 (38.5)399 (37.8)African American582 (57.3)608 (57.5)Hispanic13 (1.3)15 (1.4)Asian/Pacific Islander12 (1.2)11 (1.0)Other17 (1.7)24 (2.3)VTE Risk Factors — no. (%)Previous VTE91 (8.9)108 (10.2)0.30Cancer92 (9.0)64 (6.0)0.01Stroke7 (0.7)4 (0.4)0.34Congestive Heart Failure103 (10.1)96 (9.1)0.45Hypercoagulable State9 (0.9)13 (1.23)0.43Sepsis/Infection218 (21.3)120 (11.4)<0.0001Mechanical Ventilation30 (2.9)23 (2.2)0.33Contraindications — no. (%)Bleeding on Admission46 (4.5)49 (4.6)0.88Platelet < 50,00024 (2.3)27 (2.6)0.75APTT > 1.390 (8.8)70 (6.6)0.06INR > 1.5120 (11.7)111 (10.5)0.38In-Hospital Mortality13 (1.3)22 (2.1)0.29Table 2Comparison of ACCP Compliance, Pharmacologic Prophylaxis and Clinical Outcomes Pre- and Post-Implementation of VTE “Smart Orderset”VariablePre-Orderset (n = 1,025)Post-Orderset (n = 1,057)p-valueACCP Compliance — no. (%)700 (68.3)908 (85.9)<0.0001Prophylaxis— no. (%)Heparin 5000 BID142 (13.9)316 (29.9)<0.0001Heparin 5000 TID451 (44.0)373 (35.3)<0.0001Enoxaparin 40 mg daily8 (0.80)13 (1.23)0.31TED/SCDS60 (5.90)205 (19.4)<0.0001None363 (35.4)150 (14.2)<0.0001Clinical Outcomes— no. (%)In-hospital VTE8 (0.8)2 (0.2)0.06VTE by 90 days post-DC25 (2.4)6 (0.6)0.001Major Bleeding3 (0.3)1 (0.1)0.47 Conclusion:A VTE prophylaxis computerized decision support “smart orderset” improves ACCP-compliant VTE prophylaxis and results in lower risk of symptomatic VTE without an increase in major bleeding. Disclosures:Streiff:BristolMyers Squibb: Research Funding; sanofi-aventis: Consultancy; Daiichi-Sankyo: Consultancy; Eisai: Member of study outcome adjudication committee; sanofi-aventis: Honoraria.

Unintended Consequences of a Standard Admission Order Set on Venous Thromboembolism Prophylaxis and Patient Outcomes

Standard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it. We conducted a retrospective cohort study using administrative and pharmacy charge data of patients admitted between 1 July 2005 and 31 December 2008 to two medical and three surgical services that implemented a standard admission order set in August 2006. The primary outcome was use of VTEP in patients with likely benefit, unclear benefit, and potential harm from VTEP prior to and following order set implementation. A total of 8,429 patients (32%) were admitted prior to and 17,635 (68%) following order set implementation. There was a small unadjusted rise in overall VTEP use after implementation (51% to 58%, p < 0.001). In multivariable models with interrupted time series analysis, patients with potential harm from VTEP had the largest increase in VTEP use at the time of implementation [adjusted odds ratio = 1.58; 95% confidence interval (CI), 1.12-2.22]. The increased likelihood of receiving VTEP in this subgroup gradually returned to baseline (adjusted odds ratio per month = 0.98; 95% CI, 0.96-0.99). Implementation of a standard admission order set transiently increased VTEP in patients with potential harm from it. Order set and guideline success should be judged based on the degree to which they successfully target patients likely to benefit from the intervention without inadvertently targeting patients potentially harmed.

Improving Sepsis Outcomes for Acutely Ill Adults Using Interdisciplinary Order Sets

The objective of the study was to measure outcomes following implementation of standardized order sets for managing patients with severe sepsis/septic shock. Sepsis is a severe illness, affecting approximately 750 000 people in the United States, with mortality rates of 28% to 50%, and costing $17 billion each year. An interdisciplinary team was created to improve early recognition and process of care in patients with severe sepsis/septic shock. Education was rolled out over 6 months, and sepsis "bundle" order sets were implemented. Adult patients (N = 674) with a diagnosis of severe sepsis or septic shock who were admitted to an emergency department or critical care unit at a 563-bed tertiary care teaching facility from May 2008 through October 2010 were included in data analysis. A plan, do, study, act methodology was used. Outcomes following project implementation were measured prospectively including appropriate recognition of patients with a diagnosis of sepsis, hospital site where the order set was initiated, and attainment of treatment goals within 6 hours of onset of severe sepsis/septic shock. When order set usage was analyzed, the use of order sets was significantly associated with meeting "6-hour goals" successfully (χ1 [n = 662] = 36.16, P < .001); order set usage explained 24% of the variation in meeting goals, R = 0.24, F1,661 = 38.51, P < .0001. Order sets improved management of septic patients through effective change in delivery systems to support evidence-based medical care. Administrative support, team collaboration, and standardized order sets can lead to improved process of care.

Standardized order sets for the treatment of severe sepsis and septic shock

Evaluation of: Thiel SW, Asghar MF, Micek ST, Reichley RM, Doherty JA, Kollef MH. Hospital-wide impact of standardized order set for the management of bacteremic severe sepsis. Crit. Care Med. 37(3), 819–824 (2009).Aggressive standardized diagnostic and therapeutic approaches to acute diseases such as acute myocardial infarction, trauma and stroke have led to improved patient survival. A standardized order set for severe sepsis and septic shock represents a similar approach. In 2001, Rivers et al., using a standardized operating procedure to treat severe sepsis and septic shock, showed a relative risk reduction of 0.34 and absolute risk reduction of 16%, with a decrease in healthcare resource consumption for patients presenting to the emergency department. Since then, similar studies have shown similar or better results. This study in particular highlights a hospital-wide initiative that further confirms that standardized order sets and operating procedures for severe sepsis and septic shock result in a significant reduction in morbidity, mortality and healthcare resource consumption. With these robust findings, future emphasis should be placed on overcoming logistical, institutional and professional barriers to the implementation of standardized order sets, which can save the life of one out of every five to six patients presenting with severe sepsis and septic shock.

Implementation of Evidence-Based Guidelines and PCA Order Sets for Opioid Naïve and Opioid Tolerant Patients

Implementation of Evidence-Based Guidelines and PCA Order Sets for Opioid Naïve and Opioid Tolerant Patients