Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment.

Background: Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. Objective: To assess utilization of a WLST order set and time to inpatient death before and after optimization. Design: A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Setting/Subjects: Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Measurements: Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. Results: A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. Conclusions: In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.

Targeting zero medication administration errors in the pediatric intensive care unit: A Quality Improvement project.

BACKGROUND: Medication errors and adverse drug events have a significant impact on mortality and morbidity among hospitalized children, and are more likely to occur in critical care settings due to the fast-paced environment and patient vulnerability. There is no exception to this rule in our pediatric intensive care unit, a 28-bed unit at a tertiary care children's hospital in Riyadh, Saudi Arabia. PROBLEM ASSESSMENT: A medication administration error rate of 6.25-8.05/1000 patient days was reported in our unit (48 errors), taking into account only errors that reached patients. Toward improving patient safety, a project was launched to reduce medication errors. DESIGN: Multidisciplinary quality improvement team reviewed baseline data and analyzed medication errors that occurred in 2019. Five Plan-Do-Study-Act cycles were implemented. As an outcome measure, the medication error rate was monitored. RESULTS: The outcome measure of medication administration error rates was monitored quarterly. An improvement of 75% during the first quarter of 2021 to a rate of zero medication errors/1000 patient days during the first quarter of 2022. A decrease in medication errors was attributed to improved situational awareness and increased compliance with assisted technology. CONCLUSION: Medication errors can be decreased by deploying various interventions utilizing human- and technology-based approaches. When it comes to reducing medication errors in the pediatric intensive care unit, a multidisciplinary approach is paramount. IMPLICATIONS FOR CLINICAL PRACTICE: This study suggests several ways to reduce medication errors. Implementing information technology systems and involving pharmacists in medication management can help prevent errors. Enhancing teamwork, communication, and collaboration among healthcare professionals is also important. Clinical risk management strategies, nursing interventions, and adherence to medication safety guidelines are essential, especially for pediatric and neonatal populations. Considering these clinical implications can guide healthcare professionals and organizations in addressing medication errors and enhancing patient safety.

A Synoptic Electronic Order Set for Placental Pathology: A Framework Extensible to Nonneoplastic Pathology.

Accurate pathologic assessment in placental pathology is mostly dependent on a complete clinical history provided by a clinical team. However, often, the necessary clinical information is lacking, and electronic order sets (EOSs), if implemented correctly, create an opportunity for entering consistent and accurate clinical data. In this viewpoint piece, we describe a framework for synoptic EOS in placental pathology. We outline the necessary data and create optional clinical data that get entered as a dropdown menu of free text. While EOSs are the best way to approach and diagnose placenta and other nonneoplastic pathologic specimens, the barriers for implementation include paper requisitions and a cultural mindset resistance. The aspiration for our synoptic EOS is to become an effective tool for communication between proceduralists and pathologists for proper diagnosis of placental specimens. Through our EOS, the appropriate and complete clinical context is conveyed from the clinical teams to the pathologist. The pathologist can easily and rapidly extract the necessary information to render an accurate and precise diagnosis. The captured data likewise become a valuable research resource.

The use of a standardized order set reduces systemic corticosteroid dose and length of stay for individuals hospitalized with acute exacerbations of COPD: a cohort study.

Background: Systemic corticosteroids (SC) are an integral part of managing acute exacerbations of COPD (AECOPD). However, the optimal dose and duration vary widely in clinical practice. We hypothesized that the use of a "PowerPlan" order set in the electronic health system (EHS) that includes a 5-day SC order would be associated with a reduced steroid dose and length of stay (LOS) for individuals hospitalized with AECOPD. Patients and methods: We conducted a retrospective cohort study of Medicare recipients discharged with an AECOPD diagnosis from our University Hospital from 2014 to 2016. Our EHS-based "COPD PowerPlan" order set included admission, laboratory, pharmacy, and radiology orders for managing AECOPD. The default SC option included intravenous methyl-prednisolone for 24 hours followed by oral prednisone for 4 days. The primary endpoint was the difference in cumulative steroid dose between the PowerPlan and the usual care group. Secondary endpoints included hospital LOS and readmission rates. Results: The 250 patients included for analysis were 62±11 years old, 58% male, with an FEV1 55.1%±23.6% predicted. The PowerPlan was used in 72 (29%) patients. Cumulative steroid use was decreased by 31% in the PowerPlan group (420±224 vs 611±462 mg, P<0.001) when compared with usual care. PowerPlan use was independently associated with decreased LOS (3 days; IQR 2-4 days vs 4 days; IQR 3-6 days, P=0.022) without affecting 30- and 90-day readmission rates. Conclusion: Use of a standardized EHS-based order set to manage AECOPD was associated with a reduction in steroid dose and hospital LOS.

An electronic alert for HIV screening in the emergency department increases screening but not the diagnosis of HIV.

OBJECTIVE: Based on US. Centers for Disease Control and Prevention recommendations, New York State enacted legislation in 2010 requiring healthcare providers to offer non-targeted human immunodeficiency virus (HIV) testing to all patients aged 13-64. Three New York City adult emergency departments implemented an electronic alert that required clinicians to document whether an HIV test was offered before discharging a patient. The purpose of this study was to assess the impact of the electronic alert on HIV testing rates and diagnosis of HIV positive individuals. METHODS: During the pre-intervention period (2.5-4 months), an electronic "HIV Testing" order set was available for clinicians to order a test or document a reason for not offering the test (e.g., patient is not conscious). An electronic alert was then added to enforce completion of the order set, effectively preventing ED discharge until an HIV test was offered to the patient. We analyzed data from 79,786 visits, measuring HIV testing and detection rates during the pre-intervention period and during the six months following the implementation of the alert. RESULTS: The percentage of visits where an HIV test was performed increased from 5.4% in the preintervention period to 8.7% (p<0.001) after the electronic alert. After the implementation of the electronic alert, there was a 61% increase in HIV tests performed per visit. However, the percentage of patients testing positive per total patients-tested was slightly lower in the post-intervention group than the pre-intervention group (0.48% vs. 0.55%), but this was not significant. The number of patients-testing positive per total-patient visit was higher in the post-intervention group (0.04% vs. 0.03%). CONCLUSIONS: An electronic alert which enforced non-targeted screening was effective at increasing HIV testing rates but did not significantly increase the detection of persons living with HIV. The impact of this electronic alert on healthcare costs and quality of care merits further examination.