Improving thiamine prescribing in alcohol use disorder using electronic decision support in a large urban academic medical center: A pre-post intervention study.

INTRODUCTION: Thiamine is the only therapy for prevention and treatment of Wernicke Encephalopathy among patients with Alcohol Use Disorder (AUD). Despite this fact, up to 75 % of inpatients with AUD are not prescribed thiamine during hospitalization. Even fewer patients are prescribed high-dose thiamine which many experts recommend should be standard of care. Previous attempts to improve thiamine prescribing for inpatients have had limited success. METHODS: We conducted an evaluation of thiamine prescribing in the year before and year after an intervention to increase high-dose thiamine prescribing. Pre-post study analysis occurred on two distinct study cohorts: those with alcohol-related diagnoses and those with elevated alcohol levels. The intervention was new electronic health record-based decision support which encouraged high-dose thiamine when any thiamine order was sought. No educational support was provided. The primary outcome was prescription of high-dose thiamine before versus after intervention. Of those with alcohol-related diagnoses, the monthly percentage of thiamine treatment courses including high-dose thiamine were graphed on a control chart. RESULTS: We examined 5307 admissions with alcohol-related diagnoses (2285 pre- and 3022 post-intervention) and 698 admissions with elevated alcohol levels (319 pre- and 379 post-intervention). Among admissions with alcohol-related diagnoses, the intervention was associated with a higher proportion of admissions receiving high-dose thiamine prescriptions in the first 24 h (4.7 % vs. 1.1 %, adjusted odds ratio 4.50, CI 2.93 to 6.89, p < 0.001). A similar difference in high-dose thiamine was seen post-intervention among admissions with elevated alcohol levels (14.3 % vs. 2.5 %, adjusted odds ratio 6.43, CI 3.05 to 13.53, p < 0.001). The control chart among those with an alcohol-related diagnosis demonstrated special cause variation: the median percentage of thiamine treatment courses including high-dose thiamine improved from 8.2 % to 13.0 %. CONCLUSIONS: Electronic decision support without educational interventions increased the use of high-dose thiamine among patients with alcohol-related diagnoses and with elevated alcohol levels during hospitalization. This increase occurred immediately in the month after the intervention and was sustained in the year-long study period after.

Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder.

BACKGROUND: Patients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. METHODS: As a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. RESULTS: Patients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). CONCLUSION: These results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.

Improving pain management for pediatric patients undergoing nonurgent painful procedures.

PURPOSE: The development of a topical analgesia protocol to improve pain management for pediatric patients undergoing nonurgent painful procedures is described. SUMMARY: Leadership from the departments of pediatrics, neonatology, obstetrics and gynecology, nursing, pharmacy, child life, and phlebotomy were chosen to develop and implement a new protocol for topical analgesia use for nonurgent painful procedures in pediatric patients. A review of the published literature on pain management in neonates, infants, children, and adolescents led to the replacement of lidocaine 2.5%-prilocaine 2.5% with liposomal lidocaine 4% topical cream on the formulary. In addition to topical analgesia, psychological and physical methods that enable children to cope successfully with anxiety-provoking and painful experiences were included as part of the education portion of implementation. Child life staff educated other staff, patients, and their parents on pain management techniques, including deep breathing, imagery, and the use of distraction tools. The protocol was transcribed onto preprinted prescriber order forms, which were made available to all pediatric inpatient units, the pediatric emergency department, and the pediatric ambulatory care clinic. A separate form was developed for neonatology. Data from before and after protocol implementation were collected and assessed. Only pediatric patients admitted to inpatient units or seen in ambulatory care clinics were included in the evaluation. The percentage of patients undergoing nonurgent painful procedures treated with topical analgesia or dorsal penile block for circumcisions rose from 2% (preimplementation of protocol) to 92% (postimplementation) (p < 0.0001, chi-square). CONCLUSION: A multidisciplinary approach to protocol development and implementation significantly increased compliance to a topical analgesia protocol for pediatric patients undergoing nonurgent painful procedures in a community medical center.