Assignment: Clinical Decision Support
Environmental characteristics that decrease success:
limited time and personnel resources
limited perceived support from peers or superiors
Clinical decision support
Clinical decision support (CDS) built within the electronic medical record (EMR) is a powerful means to leverage guideline uptake. CDS encompasses a variety of approaches to provide clinicians, staff, patients, and other users with timely, relevant information that can improve decision making, prevent errors, and enhance health and health care.41 Qualitative research has defined 3 categories of CDS: (1) Alerting CDS: alerts and reminders that fire to deliver information and interrupt workflow; (2) Workflow CDS: eases data entry, documentation, and resource location, and (3) Cognitive CDS: provides a patient management and planning overview.42 CDS tools and interventions include computerized alerts and reminders, order sets, patient data reports and dashboards, documentation templates, diagnostic support, and clinical workflow tools.41 CDS tools allow for dissemination of the right information to the right people at the right time. At TCH, we offer our clinicians a plethora of CDS tools, including algorithms, evidence-based order sets, suggestion records, interdisciplinary plans of care (IPOCs), best practice alerts (BPAs), and navigators. Suggestion records use discrete variables from the patient chart to promote the use of evidence-based order sets by passively suggesting targeted order set use to the ordering clinician on the order entry screen. Interdisciplinary plans of care display goal-driven interventions for the entire care team. Best practice alerts are pop-ups that prompt a clinician to address an issue before continuing and can be programmed with hard stops.
Algorithms or flowcharts provide a visual representation of the practice recommendations. Evidence-based order sets allow for timely application of evidence at the bedside. Orders that are supported by evidence can be defaulted and orders that are not supported by evidence are intentionally omitted or listed last on order lists if minimal evidence supports their use. For example, chest radiographs for bronchiolitis are not offered on ED- based bronchiolitis order sets, and generic oral antibiotic choices are listed first on options for community- acquired pneumonia order sets and other ED- based infectious disease related order sets. Order sets may have hyperlinks to resources (eg, clinical standard, algorithm, or other pertinent internal or external resources) to provide transparency to CDS. In addition, clinical and information services governance structures at Texas Children’s Hospital prohibit consensus- or silo-based order set builds if an existing evidence-based order set exists.
The implementation of evidence-based order sets, clinical guidelines, and QI interventions driven by a CDS tool for early recognition of severe sepsis and septic shock at our institution led to an improvement in a number of quality metrics. The trigger tool, designed as a hard stop alert, had an 81% sensitivity and 99.9% negative predictive value.43 After implementation of the protocol, measurement of impact compared to baseline data revealed significant improvements in time from triage to first bolus (decrease from a median of 56 to 22 minutes) and triage to first antibiotics (decrease from a median of 130 to 38 minutes).44
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