The use of clinical decision support (CDS) to elevate patient care is a solid strategy in any healthcare environment. And while the benefits of decision-support tools are expected to be far reaching across the patient-care continuum, there are likely no areas more primed for realizing their potential than critical care.
Critical care poses a unique challenge and opportunity for evidence-based medicine (EBM) because the stakes are so high when less-than-optimum choices are made. Forgetting to write down just one order can have life-threatening consequences – a reality for even the most detail-oriented physician. Thus, when clinicians can rely on CDS to help ensure that nothing is overlooked, a hospital is poised for greater control over its efforts to achieve the highest level of patient care and safety.
Also a reality for critical care is the fact that industry best practices tend to be moving targets, with new research and outcomes constantly coming online. Physicians in this environment are used to this continuous change and are much more open to the use of CDS if it will alleviate the pressure that comes with staying abreast of the latest evidence.
To this end, many hospitals are realizing the integral role that evidence-based order sets can play in meeting national quality expectations and metrics going forward – especially since faulty decisions can have dire consequences.
Evidence-based order sets provide a foundation for elevating patient care. The challenge for many hospitals is finding the resources needed to deploy these tools efficiently and effectively into physician workflows. That’s where advanced technology and automation play key roles.
Sibley Memorial’s EBM challenge
Consistency of care and adoption of EBM into clinical practice have been central tenets of Sibley Memorial Hospital’s efforts to raise the bar on quality to exceed regulatory standards. A 328-bed acute-care hospital in Washington D.C., the facility set out to overcome the challenges of a decentralized order-set strategy and limited adoption of practices that support the latest evidence.
Specifically, Sibley had in place a hybrid medical record system that included both electronic and paper-based processes. Without a centralized, electronic system for organizing order sets and forms, the hospital faced an uphill battle over version control and standardization of processes.
Further, the system for developing new order sets was fragmented at best, beginning with development in a departmental committee and proceeding through the daunting process of gaining approvals from numerous other committees. Without any real coordination between committees, the process could take months, making the effort to actually get an order set incorporated into workflow monumental. In the case of critical care – where the latest evidence changes rapidly – order sets could become outdated before they even made it into the clinical workflow.
Community-based hospitals like Sibley also face unique challenges to the adoption of EBM because the sharing of knowledge and new ideas doesn’t occur at the same pace as it does in a university hospital or academic setting. The ability to demonstrate the rationale behind certain practice changes is essential in these environments, as changes in clinical practice or workflow tend to receive pushback and can be painstakingly slow.
To address Sibley’s needs going forward, a project team was assembled to identify an appropriate solution to speed up and centralize the order-set development process, ensure that the latest evidence was attached to CDS and advance the practice of EBM. The obvious starting point was the ICU.
Advanced technology overcomes challenges
Sibley initiated a six-month pilot in early 2011 wherein paper-based order sets used in the ICU and joint-replacement program were converted to ProVation Order Sets, powered by UpToDate Decision Support. In addition to a robust project-management function that accelerates the development cycle, the electronic order-set solution features direct links to supporting medical evidence and an automated maintenance tool to ensure that the order sets stay current.
Most importantly, the software’s interfaces allow for fast deployment into the hospital’s CPOE system. Though a fully automated interface with any system is impossible, order-set tools with customizable interfaces make it easier to upload approved order sets into the CPOE system with limited manual intervention.
A key element to the successful rollout and implementation of the order-set technology was the identification of physician champions to oversee the process. Due to physician time constraints, as well as the need for consensus going forward, Sibley determined it would be impossible to have mass involvement. Thus, a limited committee structure was established to ensure that the program could move forward as smoothly as possible. Physician champions and subject-matter experts were identified in the targeted clinical areas to facilitate this process.
Once rolled out, order sets successfully served as a crucial checklist in the ICU to make sure nothing was missed or overlooked. The department staff was also able to draw on the integrated evidence to implement more efficient programs.
For example, in Sibley’s prior ICU admission orders, a pre-printed order set existed that listed an option for “stress ulcer prophylaxis.” This created a situation where the majority of patients admitted to the ICU were placed on prophylaxis, often including patients at low risk for developing stress ulcers. This created higher costs for the hospital as patients were often continued on prophylaxis until discharge from the hospital. That order set was revised based on the template available within ProVation Order Sets and linked to evidence provided by UpToDate to support the change in prophylaxis orders. This changeover has created a more effective and cost-efficient process.
As part of the ICU pilot, Sibley was also able to implement a nutrition order set that did not previously exist. Prior to the availability of order sets, a nutrition consult had to be obtained before enteral nutrition could be initiated. Now, clinicians feel much more comfortable implementing nutrition support in a more timely fashion.
UpToDate has been widely embraced, and the physician community has gained a great deal of confidence in the evidence provided. Direct links to UpToDate are provided for much of the order-set content, allowing physicians to quickly and easily click through to the supporting evidence to see the rationale behind the order set. This is especially valuable when the order set represents a change in typical practice patterns.
End result
The extent to which Sibley’s medical staff has embraced order sets and CPOE has far exceeded the initial expectations. When a new process is carefully thought out and well executed, the physician community is much more likely to embrace its benefits going forward. For example, the hospital’s ICU admission order set ultimately went from one page to five, but the end result has been the execution of more efficient and effective patient care alongside improved workflows.
By leveraging advanced order-set technology coupled with evidence-based decision support in the ICU, Sibley has been able to standardize care on a high level. This successful effort positions the organization to raise the bar on patient quality and places it at the forefront of the national healthcare movement.
About the author:
Hasan Zia, M.D., is CMIO and director of critical care and emergency surgery for Sibley Memorial Hospital, a 328-bed acute care hospital in Washington, D.C. For more information on Wolters Kluwer Health solutions, click here.
