Clinical decision support systems to improve utilization of thromboprophylaxis: a review of the literature and experience with implementation of a computerized physician order entry program.

OBJECTIVE: A literature review was conducted of studies investigating the effectiveness of paper- and computer-based clinical decision support systems (CDSS) used with or without educational programs designed to increase the use of venous thromboembolism (VTE) prophylaxis. METHODS: Medline was searched on August 9, 2010, without limits on publication year, but with restrictions to English-language articles only. The search terms used were "venous thromboembolism," "deep vein thrombosis," "pulmonary embolism," "prophylaxis," "thromboprophylaxis," "computerized," "computerised," "decision support," "alerts," "reminder," "paper system," "risk assessment," and "risk score." All types of studies regarding the effects of CDSS on VTE prophylaxis rates were included. Studies were included if ≥ 1 post-implementation outcome was measured, such as rates of VTE, rates of prophylaxis prescribing, or guideline-adherence measures. RESULTS: Studies evaluating paper-based CDSS used different strategies, including risk-assessment forms with prophylaxis recommendations, standard order sets, and preprinted sticker reminders on patient notes. Paper-based systems consistently improved prophylaxis rates; however, in most studies, there was still room for improvement. Furthermore, the effect of paper-based CDSS on VTE rates was not conclusively established. Studies evaluating computer-based systems used approaches including risk-assessment models integrated in the computerized physician order entry system, with or without alerts, and automatic reminders on operating schedules. CONCLUSION: Computerized systems are associated with substantial improvements in the prescribing of appropriate prophylaxis and reductions in VTE events, particularly in medical patients. More robust systems can be established with computer-based rather than paper-based CDSS. A drawback of computerized systems is that some hospitals may not have adequate information technology system resources.

Utilization of the office, hospital and emergency department for adult sickle cell patients: a five-year study.

Sickle cell disease (SCD) is a hematological disorder that is manifested primarily by severe pain and chronic organ damage. Little normative data exists on what the usual healthcare utilization is of a population of SCD patients, especially adults. Our study analyzed the office, emergency department (ED) and hospital use data for 142 patients who received care for three consecutive years. Relationships between health service use, patient age, gender and sickle cell phenotype were described. Multivariate analyses studied relationships between demographic and clinical characteristics and levels of office, independent ED and inpatient encounters over a five-year period (1997-2001). We found female patients were older and had less ED and hospital admissions. The 20% highest inpatient utilizers accounted for 54% of the ED total visits, 52% of the ED independent visits, 54% of hospital bed days and 24% of office visits. The ED was a common place for utilization, with a mean of 7.4 visits per patient year, a third of which resulted in a hospital admission. The healthcare utilization of our adult sickle cell population is very complex, with a subset of our patients accounting for a majority of the resources used and female patients living longer but with less ED and hospital admissions.

Bloodstream infections in hospitalized adults with sickle cell disease: a retrospective analysis.

Bloodstream infections (BSI) are a common cause of morbidity and mortality in people with sickle cell disease (SCD). In children with SCD, BSI are most often caused by encapsulated organisms. There is a surprising paucity of medical literature that is focused on evaluating SCD adults with BSI. We reviewed the charts of adults with SCD and BSI who were admitted to our hospital between April 1999 and August 2003. During this period a total of 1,692 hospital admissions for 193 adults with SCD were identified and 28% of these patients had at least 1 episode of positive blood cultures, with 69 episodes (17%) considered true BSI. Nosocomial BSI occurred in 34 episodes (49%). Among community BSI, in contrast to BSI in children with SCD, Streptococcus pneumoniae was rarely encountered. A high incidence of staphylococcal BSI in adults with SCD was noted. Twenty-eight percent of all BSI were caused by Staphylococcus aureus, and 15 of 22 isolates (68%) of these were methicillin-resistant. Gram-negative organisms, anaerobes, and yeast were found in 21 (27%), 3 (4%), and 4 isolates (5%) of BSI, respectively. Since over 80% of BSI were considered catheter-related, the higher incidence of gram-positive bacterial infections was likely due to the presence of indwelling central venous catheters. Empiric therapy for adults with SCD suspected of having BSI, especially in the presence of indwelling central venous catheters, should include antimicrobial therapy targeted at gram-positive bacteria (especially MRSA) and gram-negative bacteria. Also, if patients are critically ill, consideration should be made to include antifungal agents. Additional research into the adult SCD population appears necessary to further define this problem.

Attitudes about patient safety: a survey of physicians-in-training.

Little is known about the attitudes of physicians-in-training on patient safety, although success in error reduction strategies requires their support. We surveyed house staff and fourth-year medical students from 1 academic institution about their perceptions of adverse patient events. Three hundred twenty-one trainees (41%) completed the survey. Most believe adverse events are preventable (61%) and think improved teamwork (88%), better procedural training (74%), and improved sign-out (70%) would reduce medical mishaps. Forty-seven percent of trainees agree computerized order entry and restricted work hours would prevent adverse events. Although 60% feel malpractice fears inhibit discussion, 80% of trainees agreed physicians must disclose adverse events to patients and grow more comfortable with disclosure as training progresses (P for trend<.01). In conclusion, trainees believe adverse events are preventable and are poised to respond to many components of the patient safety movement.