A combined paging alert and web-based instrument alters clinician behavior and shortens hospital length of stay in acute pancreatitis.

OBJECTIVES: There are many published clinical guidelines for acute pancreatitis (AP). Implementation of these recommendations is variable. We hypothesized that a clinical decision support (CDS) tool would change clinician behavior and shorten hospital length of stay (LOS). DESIGN/SETTING: Observational study, entitled, The AP Early Response (TAPER) Project. Tertiary center emergency department (ED) and hospital. PARTICIPANTS: Two consecutive samplings of patients having ICD-9 code (577.0) for AP were generated from the emergency department (ED) or hospital admissions. Diagnosis of AP was based on conventional Atlanta criteria. The Pre-TAPER-CDS-Tool group (5/30/06-6/22/07) had 110 patients presenting to the ED with AP per 976 ICD-9 (577.0) codes and the Post-TAPER-CDS-Tool group (5/30/06-6/22/07) had 113 per 907 ICD-9 codes (7/14/10-5/5/11). INTERVENTION: The TAPER-CDS-Tool, developed 12/2008-7/14/2010, is a combined early, automated paging-alert system, which text pages ED clinicians about a patient with AP and an intuitive web-based point-of-care instrument, consisting of seven early management recommendations. RESULTS: The pre- vs. post-TAPER-CDS-Tool groups had similar baseline characteristics. The post-TAPER-CDS-Tool group met two management goals more frequently than the pre-TAPER-CDS-Tool group: risk stratification (P<0.0001) and intravenous fluids >6L/1st 0-24 h (P=0.0003). Mean (s.d.) hospital LOS was significantly shorter in the post-TAPER-CDS-Tool group (4.6 (3.1) vs. 6.7 (7.0) days, P=0.0126). Multivariate analysis identified four independent variables for hospital LOS: the TAPER-CDS-Tool associated with shorter LOS (P=0.0049) and three variables associated with longer LOS: Japanese severity score (P=0.0361), persistent organ failure (P=0.0088), and local pancreatic complications (<0.0001). CONCLUSIONS: The TAPER-CDS-Tool is associated with changed clinician behavior and shortened hospital LOS, which has significant financial implications.

Implementation of a small bowel obstruction guideline improves hospital efficiency.

BACKGROUND: We performed an internal review of triage decisions and outcomes for all patients admitted for small bowel obstruction (SBO). Concern for potential delays in operation led to formalization of an institution-wide SBO management guideline. We hypothesized that use of the guideline would improve initial triage and patient outcomes. METHODS: Members of the departments of surgery, medicine, and emergency medicine created a SBO service triage and initial management guideline that was instituted in 2011 after education and a multidisciplinary Grand Rounds on the subject. Administrative data from fiscal year 2010 (FY2010) was compared with the first 6 months of 2011. Time to computed tomography scan, the OR, general surgery (GS) consultation, and hospital duration of stay were collected and compared for those admitted to a medicine service before (Med2010) and after (Med2011) the guideline and those admitted to a general surgery service before (GS2010) and after (GS2011) the guideline. Groups were compared with Student t test and χ2 analysis. RESULTS: There were 490 SBO admissions in FY2010 and 240 in the first 6 months of 2011. After implementation of the guidelines, the percent of SBO patients admitted to GS2011 increased from 55 to 66% (P < .01). The percent of patients admitted to a medicine service requiring operation for SBO did not change from 14 to 7% for Med2011, but there was a shorter time to GS consultation (P < .001). Time from admission to operation decreased from 0.9 to 0.4 days (P < .05) with a mean decrease in hospital duration of stay of 2 days (8 ± 6 compared with 6 ± 4 days, P < .001) for those admitted during GS2011. CONCLUSION: Implementation of a hospital-wide SBO guideline that addressed initial management and triage shortened time to operative intervention and hospital duration of stay for patients requiring operative therapy for SBO.