Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay.

OBJECTIVE: Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS: Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS: Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS: Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.

Reduction of central venous catheter associated blood stream infections following implementation of a resident oversight and credentialing policy.

BACKGROUND: This study assesses the impact that a resident oversight and credentialing policy for central venous catheter (CVC) placement had on institution-wide central line associated bloodstream infections (CLABSI). We therefore investigated the rate of CLABSI per 1,000 line days during the 12 months before and after implementation of the policy. METHODS: This is a retrospective analysis of prospectively collected data at an academic medical center with four adult ICUs and a pediatric ICU. All patients undergoing non-tunneled CVC placement were included in the study. Data was collected on CLABSI, line days, and serious adverse events in the year prior to and following policy implementation on 9/01/08. RESULTS: A total of 813 supervised central lines were self-reported by residents in four departments. Statistical analysis was performed using paired Wilcoxon signed rank tests. There were reductions in median CLABSI rate (3.52 vs. 2.26; p = 0.015), number of CLBSI per month (16.0 to 10.0; p = 0.012), and line days (4495 vs. 4193; p = 0.019). No serious adverse events reported to the Pennsylvania Patient Safety Authority. CONCLUSIONS: Implementation of a new CVC resident oversight and credentialing policy has been significantly associated with an institution-wide reduction in the rate of CLABSI per 1,000 central line days and total central line days. No serious adverse events were reported. Similar resident oversight policies may benefit other teaching institutions, and support concurrent organizational efforts to reduce hospital acquired infections.

Effect of standardized electronic discharge instructions on post-discharge hospital utilization.

BACKGROUND: Several physician organizations and the Centers for Medicare and Medicaid Services (CMS) support compliance measures for written discharge instructions. CMS has identified clear discharge instructions with specific attention to medication management as a necessary intervention. OBJECTIVE: We tested the hypothesis that implementing a standardized electronic discharge instructions document with embedded computerized medication reconciliation would decrease post-discharge hospital utilization. DESIGN: Retrospective pre- and post-implementation comparison cohort study. PATIENTS: Subjects were hospitalized patients age 18 and older discharged between November 1, 2005 and October 31, 2006 (n = 16,572) and between March 1, 2007 and February 28, 2008 (n = 17,516). INTERVENTION: Implementation of a standardized, templated electronic discharge instructions document with embedded computerized medication reconciliation on December 18, 2006. MAIN MEASURES: The primary outcome was a composite variable of readmission or Emergency Department (ED) visit within 30 days of discharge. Secondary outcomes were the individual variables of readmissions and ED visits within 30 days. KEY RESULTS: The implementation of standardized electronic discharge instructions with embedded computerized medication reconciliation was not associated with a change in the primary composite outcome (adjusted OR 1.04, 95% CI 0.98-1.10) or the secondary outcome of 30-day ED visits (adjusted OR 0.98, 95% CI 0.98-1.10). There was an unexpected small but statistically significant increase in 30-day readmissions (adjusted OR 1.08, 95% CI 1.01-1.16). CONCLUSIONS: Implementation of standardized electronic discharge instructions was not associated with reduction in post-discharge hospital utilization. More studies are needed to determine the reasons for post-discharge hospital utilization and to examine outcomes associated with proposed process-related recommendations.