Implementing a clinical decision support tool to increase early peanut introduction guidance.

BACKGROUND: General pediatric providers are the front line for early peanut introduction discussions, but many providers believe that they are ill-equipped to handle such discussions, as the guidelines have changed quickly. OBJECTIVE: We hypothesized that a clinical decision support (CDS) tool could improve discussions of peanut introduction. METHODS: CDS tools were designed by stakeholders, improved through usability testing, and integrated into the current note templates. On the basis of queries of electronic health records, we did a preperformance versus postperformance evaluation of conversations regarding peanut introduction, barriers to peanut introduction, and percentage of 12-month well-child checkups (WCCs) that resulted in successful introduction of peanut. Providers completed surveys before and after intervention to assess their awareness of early peanut introduction and comfort using the CDS tools. RESULTS: Providers' awareness of early peanut introduction guidelines increased from 17.8% to 66.7% after the CDS tool was implemented; 79.1% of the providers were comfortable using the tool. The CDS tool improved peanut introduction conversations at the 4-month WCC from 2.4% to 81.2%, at the 6-month WCC from 3.0% to 84.2%, and at the 12-month WCC from 2.7% to 82.9%. In all, 56.6% of families had a plan to introduce peanut at the 4-month WCC. Of those who did not have a plan, the most common barrier was the family's unawareness of the benefits of early peanut introduction. At the 12-month WCC, 62.8% of families had introduced peanut without concerns. CONCLUSION: A point-of-care CDS tool encouraged more discussions of early peanut introduction between general pediatric providers and all patients. CDS tools should be considered in quality improvement projects as an implementation method for the most up-to-date guidelines.

Associations between Child Opportunity Index and Pediatric Cardiac Surgical Outcomes.

OBJECTIVE: To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia. STUDY DESIGN: In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts. Descriptive statistics, univariable analysis, and multivariable regression models were employed to assess associations between variables and outcomes. RESULTS: Of the 7460 index surgeries, 3798 (51%) met eligibility criteria. Presence of an adverse outcome, defined as either mortality or 1 of several other major postoperative morbidities, was significantly associated with COI in the univariable model (P = .008), but not the multivariable regression model (P = .39). Postoperative hospital length of stay was significantly associated with COI (P < .001) in univariable and multivariable regression models. There was no significant association between COI and readmission within 30 days of hospital discharge in univariable (P < .094) and multivariable (P = .49) models. CONCLUSION: COI is associated with postoperative hospital length of stay but not all outcomes in patients after congenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity.

Integrating structured and unstructured data for timely prediction of bloodstream infection among children.

BACKGROUND: Hospitalized children with central venous lines (CVLs) are at higher risk of hospital-acquired infections. Information in electronic health records (EHRs) can be employed in training deep learning models to predict the onset of these infections. We incorporated clinical notes in addition to structured EHR data to predict serious bloodstream infections, defined as positive blood culture followed by at least 4 days of new antimicrobial agent administration, among hospitalized children with CVLs. METHODS: Structured EHR information and clinical notes were extracted for a retrospective cohort including all hospitalized patients with CVLs at a single tertiary care pediatric health system from 2013 to 2018. Deep learning models were trained to determine the added benefit of incorporating the information embedded in clinical notes in predicting serious bloodstream infection. RESULTS: A total of 24,351 patient encounters met inclusion criteria. The best-performing model restricted to structured EHR data had a specificity of 0.951 and positive predictive value (PPV) of 0.056 when the sensitivity was set to 0.85. The addition of contextualized word embeddings improved the specificity to 0.981 and PPV to 0.113. CONCLUSIONS: Integrating clinical notes with structured EHR data improved the prediction of serious bloodstream infections among pediatric patients with CVLs. IMPACT: Developed an advanced infection prediction model in pediatrics that integrates the structured and unstructured EHRs. Extracted information from clinical notes to do timely prediction in a clinical setting. Developed a deep learning model framework that can be employed in predicting rare events in a complex and dynamic environment.

A single-center model for implementation of SLEDAI documentation adherence in childhood-onset systemic lupus erythematosus (cSLE).

BACKGROUND: Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease with variable disease expression but noted association with significant disease-related damage, morbidity, and mortality. The European Alliance of Associations for Rheumatology (EULAR) recommends routine monitoring of SLE through validated disease activity and chronicity indices, including the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Despite this, physician adherence with SLEDAI documentation remains elusive at various academic institutions. The aim of our study was to determine baseline SLEDAI documentation rates at our center and assess the change in adherence in SLEDAI documentation rate with electronic clinical decision support (CDS) reminders facilitated through the electronic medical record (EMR) over a 2-year period. METHODS: All SLE encounters over a 24-month period at a pediatric academic center were reviewed in order to obtain baseline SLEDAI documentation percentages. Physicians subsequently received monthly email reminders, initiated at month 4 of project initiation, with subsequent CDS reminder 13 months after project initiation prompted by anti-dsDNA lab result. Chart review was repeated continuously for each provider, and SLEDAI documentation rates were emailed to each provider monthly. Physicians completed a post-intervention survey regarding barriers to SLEDAI documentation at the end of the study. RESULTS: A total of 1980 SLE encounters were reviewed for this study. Baseline SLEDAI documentation rates were 10%. Following the introduction of monthly emails reminding physicians to document SLEDAI, rates increased to 55%. After the initiation of electronic in-basket reminders prompted by lab results, rates increased to 60%. Noted barriers to documentation were cited to be forgetfulness (67%) and lack of time (33%). CONCLUSION: Our study demonstrates that monthly email reminders as well as EMR-mediated electronic in-basket reminders increased SLEDAI documentation rates at an academic center. Noted barriers to documentation were reported to be forgetfulness (67%) and lack of time (33%).

Influenza Vaccination Receipt in Pediatric Patients With Cancer or Sickle Cell Disease.

BACKGROUND: Influenza causes greater morbidity in children with cancer or sickle cell disease (SCD). Literature on influenza vaccination receipt for these populations is limited in low-vaccination states. Outpatient interventions improve vaccine receipt but isolated inpatient interventions remain unstudied. PROCEDURE: We reviewed influenza vaccine receipt of children with cancer or SCD treated at Children's Healthcare of Atlanta during three influenza seasons. We implemented a clinical decision support intervention during an influenza season and compared influenza vaccine receipt preintervention and postintervention among admitted children. RESULTS: The oncology cohort (N=1548, 60% to 62%) and the SCD cohort (N=2549, 61% to 65%) had similar-to-higher vaccination receipt to the United States (58% to 64%, P =0.01 to 0.79) and Georgia (51% to 56%, P <0.01). The intervention did not significantly improve vaccination receipt for admitted children with cancer (40% vs. 56%, P =0.05 to 0.88) or SCD (44% vs. 56%, P =0.01). Regression modeling also found no significant increase in vaccine receipt (hematologic malignancy: 0.8 [0.73 to 0.98], solid tumor: 0.9 [0.80 to 1.90], central nervous system tumor: 0.9 [0.71 to 1.14], SCD: 0.9 [0.85 to 0.99]). CONCLUSIONS: Children with cancer and SCD have similar-to-greater influenza vaccination receipt compared with Georgia and the United States. An inpatient intervention did not significantly improve influenza vaccine receipt in these patient cohorts. Future studies are needed to identify alternative approaches to improving vaccine receipt in these cohorts.

Impact on Emergency Department Interventions After Implementing a Guideline Based on the Pediatric Emergency Care Applied Research Network Prediction Rule for Identifying Low-Risk Febrile Infants 29 to 60 Days Old.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown. OBJECTIVE: To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department. METHODS: This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients. RESULTS: Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed. CONCLUSIONS: After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.

Cost-effectiveness of a community-based intervention for reducing the transmission of Schistosoma haematobium and HIV in Africa.

Epidemiological studies from sub-Saharan Africa show that genital infection with Schistosoma haematobium [corrected] may increase the risk for HIV infection in young women. Therefore, preventing schistosomiasis has the potential to reduce HIV transmission in sub-Saharan Africa. We developed a transmission model of female genital schistosomiasis and HIV infections that we fit to epidemiological data of HIV and female genital schistosomiasis prevalence and coinfection in rural Zimbabwe. We used the model to evaluate the cost-effectiveness of a multifaceted community-based intervention for preventing schistosomiasis and, consequently, HIV infections in rural Zimbabwe, from the perspective of a health payer. The community-based intervention combined provision of clean water, sanitation, and health education (WSH) with administration of praziquantel to school-aged children. Considering variation in efficacy between 10% and 70% of WSH for reducing S. haematobium [corrected] transmission, our model predicted that community-based intervention is likely to be cost-effective in Zimbabwe at an aggregated WSH cost corresponding to US $725-$1,000 per individual over a 20-y intervention period. These costs compare favorably with empirical measures of WSH provision in developing countries, indicating that integrated community-based intervention for reducing the transmission of S. haematobium [corrected] is an economically attractive strategy for reducing schistosomiasis and HIV transmission in sub-Saharan Africa that would have a powerful impact on averting infections and saving lives.

Accurate Dosing Weight: When the 10% Really Matters.

INTRODUCTION: Children are at increased risk of medication-associated adverse events, often due to weight-based dosing errors. We aimed to reduce the proportion of medications that were administered where the dosing weight was ≥ 10% different from the recorded weight. METHODS: We adopted in-situ usability testing to iteratively improve design of clinical decision support that would enable accurate dosing weight documentation by prompting clinicians to update weight if recorded weight was > 10% different and it had been at least 7 days since the last dosing weight update. RESULTS: The proportion of medication administrations with difference >10% between their recorded weight and dosing weight decreased from 13.1% (56,256/ 429,006) in the baseline period to 9.5% (35,560 / 372,443) in the intervention period (P < 0.001). DISCUSSION AND CONCLUSION: User-centered design of an interruptive alert improved the accuracy of dosing weights during medication administrations without substantial alert burden. In-situ usability testing is an effective approach to rapidly obtain feedback from frontline users and iterate on the design to effect desired behavior changes.

Efficient Workflow Analysis to Address Paper Persistence in Tuberculin Testing.

Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

Association of patient photographs and reduced retract-and-reorder events.

Background: Wrong-patient order entry (WPOE) is a potentially dangerous medical error. It remains unknown if patient photographs reduce WPOE in the pediatric inpatient population. Materials and Methods: Order sessions from a single pediatric hospital system were examined for retract-and-reorder (RAR) events, a surrogate WPOE measure. We determined the association of patient photographs with the proportion of order sessions resulting in a RAR event, adjusted for patient, provider, and ordering context. Results: In multivariable analysis, the presence of a patient photo in the electronic health record was associated with 40% lower odds of a RAR event (aOR: 0.60, 95% CI: 0.48-0.75), while cardiac and ICU contexts had higher RAR frequency (aOR: 2.12, 95% CI: 1.69-2.67 and 2.05, 95% CI: 1.71-2.45, respectively). Discussion and Conclusion: Patient photos were associated with lower odds of RAR events in the pediatric inpatient setting, while high acuity locations may be at higher risk. Patient photographs may reduce WPOE without interruptions.

CIC 2023: A Discount Approach to Reducing Nursing Alert Burden.

Background and Significance Numerous programs have arisen to address interruptive clinical decision support (CDS) with the goals of reducing alert burden and alert fatigue. These programs often have standing committees with broad stakeholder representation, significant governance efforts, and substantial analyst hours to achieve reductions in alert burden which can be difficult for hospital systems to replicate. Objective To reduce nursing alert burden with a primary nurse informaticist and small support team through a quality improvement approach focusing on high volume alerts. Methods Target alerts were identified from the period of January 2022 to April 2022 and four of the highest firing alerts were chosen initially, which accounted for 43% of all interruptive nursing alerts and an estimated 86 hours per month of time across all nurses occupied resolving these alerts per month. Work was done concurrently for each alert with design changes based on the Five Rights of CDS and following a quality improvement framework. Priority for work was based on operational engagement for design review and approval. Once initial design changes were approved, alerts were taken for in-situ usability testing and additional changes were made as needed. Final designs were presented to stakeholders for approval prior to implementation. Results The total number of interruptive nursing alert firings decreased by 58% from pre-intervention period (01/01/2022 - 06/30/2022) to post-intervention period (07/01/2022 - 12/31/2022). Action taken on alerts increased from 8.1 % to 17.3%. The estimated time spent resolving interruptive alerts summed across all nurses in the system decreased from 197 hours/month to 114 hours/month. Conclusion While CDS may improve use of evidence-based practices, implementation without a clear framework for evaluation and monitoring often results in alert burden and fatigue without clear benefits. An alert burden reduction effort spearheaded by a single empowered nurse informaticist efficiently reduced nursing alert burden substantially.

Current Inpatient Screening Practices for Sexual History and STIs: An Opportunity to Seize.

The American Academy of Pediatrics recommends utilizing hospitalizations as an opportunity to provide sexual health screenings for adolescents. This study aimed to describe the current practice of sexual history documentation (SHxD) and sexually transmitted infection (STI) testing among adolescents admitted to a pediatric hospital medicine service. Retrospective cross-sectional study of adolescents (14-19 years old) admitted to the PHM service from 2017-2019 was performed at an academic children's health system. Patient (demographics, history of complex chronic condition, and insurance), hospitalization (length of stay, diagnosis, STI tests ordered/results), and physician (level of training and gender) characteristics were extracted for each encounter. A natural language processing algorithm identified the presence of SHxD. Univariate analysis and multivariable analysis were performed to detect factors associated with SHxD and STI screening. The prevalence of STIs was calculated for those who were tested. Out of 2242 encounters, SHxD and STI testing rates were 40.9% and 17.2%, respectively. Patient gender, race, lack of complex chronic condition, and resident involvement were predictive of SHxD and STI testing. SHxD increased the odds of STI testing significantly (OR 5.06, CI 3.90-6.58). Among those who were tested, the prevalence of STIs was highest for chlamydia (37/329, 11.2%). Overall, sexual health screening rates remain low in the hospital setting and future improvement initiatives are needed.

Implementation of Clinical Decision Support to Identify and Improve Treatment for Severe PIVIE.

Pediatric patients are at high risk of peripheral intravenous infiltration or extravasation (PIVIE) leading to injury and increased costs. Most of the work in addressing PIVIE has focused on the implementation of workflow bundles and evidenced based guidelines. This project showed that Clinical Decision Support can be used to help support identification and treatment of Severe PIVIE through use of an interruptive alert that increases placement of vascular access team consults.

Clinical Decision Support Principles for Quality Improvement and Research.

Pediatric hospitalists frequently interact with clinical decision support (CDS) tools in patient care and use these tools for quality improvement or research. In this method/ology paper, we provide an introduction and practical approach to developing and evaluating CDS tools within the electronic health record. First, we define CDS and describe the types of CDS interventions that exist. We then outline a stepwise approach to CDS development, which begins with defining the problem and understanding the system. We present a framework for metric development and then describe tools that can be used for CDS design (eg, 5 Rights of CDS, "10 commandments," usability heuristics, human-centered design) and testing (eg, validation, simulation, usability testing). We review approaches to evaluating CDS tools, which range from randomized studies to traditional quality improvement methods. Lastly, we discuss practical considerations for implementing CDS, including the assessment of a project team's skills and an organization's information technology resources.

Realizing the Full Potential of Clinical Decision Support: Translating Usability Testing into Routine Practice in healthcare operations.

BACKGROUND: Clinical Decision Support (CDS) tools have a mixed record of effectiveness, often due to inadequate alignment with clinical workflows and poor usability. While there's a consensus that usability testing methods address these issues, in practice, usability testing is generally only used for selected projects (such as funded research studies). There is a critical need for CDS operations to apply usability testing to all CDS implementations. OBJECTIVES: In this State of the Art / Best Practice paper, we share challenges with scaling usability in healthcare operations and alternative methods and CDS governance structures to enable usability testing as a routine practice. METHODS: We coalesce our experience and results of applying guerilla in-situ usability testing to over 20 projects in 1 year period with the proposed solution. RESULTS: We demonstrate the feasibility of adopting "guerilla in-situ usability testing" in operations and their effectiveness in incorporating user feedback and improving design. CONCLUSION: Although some methodological rigor was relaxed to accommodate operational speed, the benefits outweighed the limitations. Broader adoption of usability testing may transform CDS implementation and improve health outcomes.

Avoiding Unintended Consequences of Pediatric Blood Order Set Updates through In Situ Usability Testing.

Background Blood product ordering is a complex process, and mistakes can lead to patient harm and poor outcomes. Orders and order sets can be designed to help mitigate errors, but major changes in design can unintentionally cause new errors. Objectives (1) Utilize formative in situ usability testing to iteratively improve the design of a redesigned blood product order set prior to go-live, (2) implement changes based on feedback derived from this testing, and (3) Compare the error rate, System Usability Scale (SUS) score, time to task completion, and click counts between the prior order set in use at the time and the revised redesigned order set. Methods A multidisciplinary project team convened to redesign blood product orders and order sets from scratch based on a review of literature and benchmarking against four pediatric academic institutions with the goal of addressing prior ordering errors. The new redesigned blood product order set was iteratively updated via in situ formative usability testing performed with available clinical users using a concurrent think-aloud protocol in real clinical environments. Errors, SUS scores, time to task completion, and click counts were assessed for the revised redesigned order set using summative testing. Results Formative usability testing with 20 participants led to seven design changes in the redesigned order set which reduced the error rate at go-live. Summative usability testing showed that even though the usability scores were only slightly improved for the revised redesigned order set, the error rates in blood orders were significantly decreased. Conclusion Usability testing can identify design errors early in the process which can be rectified prior to implementation, thus avoiding unintended consequences of changes.

Development and evaluation of trigger tools to identify pediatric blood management errors.

BACKGROUND: Pediatric patient blood management (PBM) programs require continuous surveillance of errors and near misses. However, most PBM programs rely on passive surveillance methods. Our objective was to develop and evaluate a set of automated trigger tools for active surveillance of pediatric PBM errors. MATERIALS AND METHODS: We used the Rand-UCLA method with an expert panel of pediatric transfusion medicine specialists to identify and prioritize candidate trigger tools for all transfused blood products. We then iteratively developed automated queries of electronic health record (EHR) data for the highest priority triggers. Two physicians manually reviewed a subset of cases meeting trigger tool criteria and estimated each trigger tool's positive predictive value (PPV). We then estimated the rate of PBM errors, whether they reached the patient, and adverse events for each trigger tool across four years in a single pediatric health system. RESULTS: We identified 28 potential triggers for pediatric PBM errors and developed 5 automated trigger tools (positive patient identification, missing irradiation, unwashed products despite prior anaphylaxis, transfusion lasting >4 hours, over-transfusion by volume). The PPV for ordering errors ranged from 38-100%. The most frequently detected near miss event reaching patients was first transfusions without positive patient identification (estimate 303, 95% CI: 288-318 per year). The only adverse events detected were from over-transfusions by volume, including 4 adverse events detected on manual review that had not been reported in passive surveillance systems. DISCUSSION: It is feasible to automatically detect pediatric PBM errors using existing data captured in the EHR that enable active surveillance systems. Over-transfusions may be one of the most frequent causes of harm in the pediatric environment.

Effectiveness of a Vendor Predictive Model for the Risk of Pediatric Asthma Exacerbation: A Difference-in-Differences Analysis.

BACKGROUND: Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric asthma outcomes remains unknown. OBJECTIVE: Determine the impact of an electronic health record (EHR) vendor-released model on outcomes for children with asthma. METHODS: The Epic Systems Risk of Pediatric Asthma Exacerbation model was implemented on February 24, 2021, for volunteer pediatric allergy and pulmonology providers as a noninterruptive risk score visible in the patient schedule view. Asthma hospitalizations, emergency department (ED) visits, or oral steroid courses within 90 days of the index visit were compared from February 24, 2019, to February 23, 2022, using a difference-in-differences design with a control group of visits to providers in the same departments. Volunteer providers were interviewed to identify barriers and facilitators to model use. RESULTS: In the intervention group, asthma hospitalizations within 90 days decreased from 1.4% (54/3,842) to 0.7% (14/2,165) after implementation with no significant change in the control group (0.9% [171/19,865] preimplementation to 1.0% [105/10,743] post). ED visits in the intervention group decreased from 5.8% (222/3,842) to 5.5% (118/2,164) but increased from 5.5% (1,099/19,865) to 6.8% (727/10,743) in the control group. The adjusted difference-in-differences estimators for hospitalization, ED visit, and oral steroid outcomes were -0.9% (95% confidence interval [CI]: -1.6 to -0.3), -2.4% (-3.9 to -0.8), and -1.9% (-4.3 to 0.5). In qualitative analysis, providers understood the purpose of the model and felt it was useful to flag high exacerbation risk. Trust in the model was calibrated against providers' own clinical judgement. CONCLUSION: This EHR vendor model implementation was associated with a significant decrease in asthma hospitalization and ED visits within 90 days of pediatric allergy and pulmonology clinic visits, but not oral steroid courses.

The Effect of Implementation of Guideline Order Bundles Into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Study.

BACKGROUND: Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations. OBJECTIVE: We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service. METHODS: We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission. RESULTS: CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%). CONCLUSIONS: The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.