Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States.
Department of Health Care Leadership and Management, Medical University of South Carolina, Charleston, SC, United States.
Int J Med Inform. 2021 Dec;156:104619. doi: 10.1016/j.ijmedinf.2021.104619. Epub 2021 Oct 15.
Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing.
This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series.
Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation.
Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.
研究表明，与生理盐水（NS）相比，静脉（IV）平衡液的使用效果更好。然而，目前仍存在显著的液体处方差异，这突显了知识与实践之间的差距。我们旨在确定导致处方差异的因素，并利用临床决策支持系统（CDSS）来增加机构内平衡液的处方量。
这是一项单中心的、基于信息学的、针对住院或在急诊接受治疗的患者的质量改进计划，包括逐步干预措施：1）确定电子病历（EHR）中计算机化医嘱录入（CPOE）系统内导致更倾向于 NS 处方的设计因素，2）临床医生教育，3）液体库存调整，4）重新设计并实施与 CDSS 集成的 IV 液体订单面板，以及 5）比较干预前后的液体处方量。通过单中断时间序列分析 EHR 衍生的处方数据。
在干预前（2019 年 3 月至 2019 年 9 月），平衡液占等渗液处方的 33%，并逐渐增加（每月 1.4%）平衡液的处方量。临床医生教育（2019 年 10 月至 2020 年 2 月）使平衡液的处方量适度增加（每月 4.4%，95%CI 1.6-7.2，p=0.01），而 CPOE 重新设计（2020 年 3 月）则立即产生了显著的（20.7%，95%CI 17.7-23.6，p<0.0001）和持续的增加（2020 年 12 月 72%的液体处方）。该干预措施在平衡液使用量较低的基线人群中效果最为显著，包括急诊医学科（增加 57%，95%CI 0.7-1.8，p<0.0001）和内科/亚专科（增加 18%，95%CI 14.4-21.3，p<0.0001）的临床医生，并且显著减少了机构内的处方差异。
将 CDSS 整合到 EHR 中可显著增加平衡液的处方量，并能持续保持这种增长。这种影响远远超过了临床医生教育的影响，突出了 CDSS 的重要性。
