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Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.

ABSTRACT: BACKGROUND:Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions. OBJECTIVES:To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected severe sepsis. DESIGN:Patient-level randomisation, single blinded. SETTING:Medical and surgical inpatient units of an academic, tertiary care medical centre. PATIENTS:1123 adults over the age of 18 admitted to inpatient wards (intensive care units (ICU) excluded) at an academic teaching hospital between November 2014 and March 2015. INTERVENTIONS:Patients were randomised to either usual care or the addition of an EHR-generated alert in response to a set of modified severe sepsis criteria that included vital signs, laboratory values and physician orders. MEASUREMENTS AND MAIN RESULTS:There was no significant difference between the intervention and control groups in primary outcome of the percentage of patients with new antibiotic orders at 3?hours after the alert (35% vs 37%, p=0.53). There was no difference in secondary outcomes of in-hospital mortality at 30 days, length of stay greater than 72?hours, rate of transfer to ICU within 48?hours of alert, or proportion of patients receiving at least 30?mL/kg of intravenous fluids. CONCLUSIONS:An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.

SUBMITTER: Downing NL

PROVIDER: S-EPMC6860967 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.

Downing Norman Lance NL Rolnick Joshua J Poole Sarah F SF Hall Evan E Wessels Alexander J AJ Heidenreich Paul P Shieh Lisa L

BMJ quality & safety 20190314 9

<h4>Background</h4>Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions.<h4>Objectives</h4>To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected ...[more]

PMID: 30872387

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Project description:ImportanceContextualizing care is a process of incorporating information about the life circumstances and behavior of individual patients, termed contextual factors, into their plan of care. In 4 steps, clinicians recognize clues (termed contextual red flags), clinicians ask about them (probe for context), patients disclose contextual factors, and clinicians adapt care accordingly. The process is associated with a desired outcome resolution of the presenting contextual red flag.ObjectiveTo determine whether contextualized clinical decision support (CDS) tools in the electronic health record (EHR) improve clinician contextual probing, attention to contextual factors in care planning, and the presentation of contextual red flags.Design, setting, and participantsThis randomized clinical trial was performed at the primary care clinics of 2 academic medical centers with different EHR systems. Participants were adults 18 years or older consenting to audio record their visits and their physicians between September 6, 2018, and March 4, 2021. Patients were randomized to an intervention or a control group. Analyses were performed on an intention-to-treat basis.InterventionsPatients completed a previsit questionnaire that elicited contextual red flags and factors and appeared in the clinician's note template in a contextual care box. The EHR also culled red flags from the medical record, included them in the contextual care box, used passive and interruptive alerts, and proposed relevant orders.Main outcomes and measuresProportion of contextual red flags noted at the index visit that resolved 6 months later (primary outcome), proportion of red flags probed (secondary outcome), and proportion of contextual factors addressed in the care plan by clinicians (secondary outcome), adjusted for study site and for multiple red flags and factors within a visit.ResultsFour hundred fifty-two patients (291 women [65.1%]; mean [SD] age, 55.6 [15.1] years) completed encounters with 39 clinicians (23 women [59.0%]). Contextual red flags were not more likely to resolve in the intervention vs control group (adjusted odds ratio [aOR], 0.96 [95% CI, 0.57-1.63]). However, the intervention increased both contextual probing (aOR, 2.12 [95% CI, 1.14-3.93]) and contextualization of the care plan (aOR, 2.67 [95% CI, 1.32-5.41]), controlling for whether a factor was identified by probing or otherwise. Across study groups, contextualized care plans were more likely than noncontextualized plans to result in improvement in the presenting red flag (aOR, 2.13 [95% CI, 1.38-3.28]).Conclusions and relevanceThis randomized clinical trial found that contextualized CDS did not improve patients' outcomes but did increase contextualization of their care, suggesting that use of this technology could ultimately help improve outcomes.Trial registrationClinicalTrials.gov Identifier: NCT03244033.

Dataset Information

Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.

Publications

Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.

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