Abdominal Pain in Inflammatory Bowel Disease: An Evidence-Based, Multidisciplinary Review.

Abdominal pain is one of the most common and impactful symptoms associated with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. A great deal of research has been undertaken over the past several years to improve our understanding and to optimize management of this issue. Unfortunately, there is still significant confusion about the underlying pathophysiology of abdominal pain in these conditions and the evidence underlying treatment options in this context. There is also a relative paucity of comprehensive reviews on this topic, including those that simultaneously evaluate pharmacological and nonpharmacological therapeutic options. In this review, our multidisciplinary team examines evidence for various currently available medical, surgical, and other analgesic options to manage abdominal pain in IBD.

Impact of a nurse navigator on a dedicated inflammatory bowel disease-focused gastroenterology clinic.

BACKGROUND: Management of inflammatory bowel disease (IBD) patients can be very challenging. Nurse navigators (NNs) have demonstrated great promise for coordinating care of complex disorders but little is known about their impact on the setting of IBD. We undertook this study to evaluate how the introduction of a NN in a dedicated IBD clinic would influence several outcomes related to patient care. METHODS: A retrospective chart review was performed evaluating Penn State IBD clinic patients receiving care a year before and after the introduction of a dedicated NN to the clinic. No-show rates, new appointments in less than 21 days, total clinic visits per month, and patient enrolment in our IBD registry and biorepository were measured prior to and after hiring of the NN between 2 providers. Each provider and their composite data were statistically compared using univariate analysis. RESULTS: After hiring the NN, there was a statistically significant decrease in combined no-show rates (P=0.02). There was no significant difference in the combined average number of new appointments in less than 21 days (P=0.62) or total clinic visits per month (P=0.09). Enrolment in the database and biorepository increased (from 83% to 90%). Finally, 97% were satisfied with the NN's services, and 94% were satisfied with the IBD education they provided. CONCLUSIONS: Hiring a NN in our clinic was associated with high patient satisfaction, reduced no-show rates, and increased research participation. Thus, incorporation of a NN can improve care in an IBD-centered gastroenterology clinic.

Incidence and impact of false-positive urine pneumococcal antigen testing in hospitalized patients.

OBJECTIVES: Immunochromatographic urine pneumococcal antigen testing (ICT) has become a common diagnostic tool for those presenting with possible invasive pneumococcal disease. The incidence and clinical impact of ICT false-positivity on hospitalized patients has not been assessed outside of specific patient subpopulations. ICT performance needs to be assessed in a real-world clinical setting. This study aims to describe the incidence and clinical impact of ICT false-positivity in a hospital setting over a 19-month period. METHODS: A retrospective cohort study was performed to assess the incidence of false-positive (FP) ICT among hospitalized patients from November 21, 2007 to June 30, 2009. The primary objective was to describe the incidence of FP ICT results. The secondary objective was to describe what clinical impact, if any, could be attributed to FP ICT results. RESULTS: During the study period, 52 positive ICT results were obtained, of which 5 (9.6%) were deemed falsely positive. Interestingly, two of the 5 FP results were from patients who had received 23-valent pneumococcal vaccine (PPV) in the 2 days prior to ICT. The management of all 5 patients was impacted by the FP results through unnecessary antimicrobial treatment and/or deferral of further clinical evaluation. CONCLUSION: Health care providers should be aware of the potential for ICT FP and should order and interpret these tests within an informed clinical framework.

Best Practices in Clinical Decision Support: the Case of Preventive Care Reminders.

BACKGROUND: Evidence demonstrates that clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety. However, implementing and maintaining effective decision support interventions presents multiple technical and organizational challenges. PURPOSE: To identify best practices for CDS, using the domain of preventive care reminders as an example. METHODS: We assembled a panel of experts in CDS and held a series of facilitated online and in-person discussions. We analyzed the results of these discussions using a grounded theory method to elicit themes and best practices. RESULTS: Eight best practice themes were identified as important: deliver CDS in the most appropriate ways, develop effective governance structures, consider use of incentives, be aware of workflow, keep content current, monitor and evaluate impact, maintain high quality data, and consider sharing content. Keys themes within each of these areas were also described. CONCLUSION: Successful implementation of CDS requires consideration of both technical and socio-technical factors. The themes identified in this study provide guidance on crucial factors that need consideration when CDS is implemented across healthcare settings. These best practice themes may be useful for developers, implementers, and users of decision support.

Use of physician education and computer alert to improve targeted use of gastroprotection among NSAID users.

BACKGROUND: Gastrointestinal (GI) hemorrhage accounts for 200-400,000 admissions in the United States annually. Around 50% of patients with bleeding ulcer have used aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Misoprostol and proton pump inhibitors (PPIs) may reduce NSAID-related upper GI tract complications in high-risk patients, but their targeted use may be suboptimal. AIM: To determine the impact of physician education, a computer alert, or both on the targeted use of GI prophylaxis in high-risk patients discharged from hospital. METHODS: To target high-risk patients, we studied cardiology telemetry and coronary care unit (CCU) services. Every 4th wk, 8 different residents managed these patients. Over a 32-wk period, residents were assigned to one of the four 8-wk groups sequentially: Group I: control; Group II: physician education, consisting of a 10-min tutorial on risk factors for NSAID-related GI complications; Group III: computer alert; and Group IV: combination of tutorial and computer alert. We reviewed all patients admitted to these cardiology services during the study period. Exclusion criteria included discharge on no ulcerogenic medications, incomplete discharge data, and inpatient death. Patients readmitted during the study period were not re-counted. Medical records were reviewed for discharge medications, past medical history, demographics, admission and discharge diagnoses, hospital days, and the Charlson comorbidity index. Other indications for acid suppression were documented. A chi(2) test was used to determine independence among all four groups. RESULTS: We enrolled 721 patients, of whom 120 (16.7%) were excluded. The remaining 601 were divided by physician intervention group and risk for NSAID-related GI complications. In total, 270 of 601 (45%) patients were discharged home on appropriate gastroprotection. The overall use of gastroprotection increased from 43 to 61% with the combination of an electronic alert and physician education (P < 0.001); among PPI-naïve patients, the rate increased from 26% to 55% (P < 0.0001). When stratified by known risk factors for GI complications of NSAIDs, the odds of receiving a gastroprotective prescription among PPI-naïve patients was 1.6 with education alone, 1.8 with electronic alert alone, and 2.9 with the combination (P < 0.0001). CONCLUSION: The combination of a computer alert and brief physician education led to an increase in the use of gastroprotection among NSAID users at the time of discharge from hospital. This effect was most evident among high-risk, PPI-naïve patients. Combining physician education and a computer alert appears to have an additive effect.

Management of peristomal pyoderma gangrenosum.

BACKGROUND: Pyoderma gangrenosum (PG) occurs in about 1% to 5% of patients with inflammatory bowel disease (IBD). Peristomal pyoderma gangrenosum (PPG) is particularly difficult to manage. STUDY DESIGN: A retrospective chart review was performed on all patients with IBD in whom PPG developed from 1997 to 2007 at the Milton S Hershey Medical Center. RESULTS: Sixteen patients (11 women) were identified. Seven had Crohn's disease (CD), seven had ulcerative colitis (UC), and two had indeterminate colitis. Six patients underwent total proctocolectomy, six patients had total abdominal colectomy (TAC), and four patients had diverting loop stomas. PPG occurred an average of 18.4+/-7.5 months after stoma creation. Twelve patients had active IBD when PPG developed. Two patients had stoma revisions and both had recurrence of the PPG with the new stoma. Medical therapy was successful in eight patients. Five patients had their stomas closed, with active PPG, and all five resolved their lesions. In four of five, surgical management was altered because of PPG (one early stoma closure, two ileal pouches without stomas, one ileal pouch with high body mass index). Of the seven and six patients treated with cyclosporine or infliximab, respectively, there were only two successes with each. CONCLUSIONS: PPG is more common in the presence of active IBD. Surgical closure of the stoma was successful in resolving PPG in all patients. Cure rate of PPG was poor with cyclosporine and only marginally better with infliximab. Medical treatment of PPG is imperfect, and the best therapy is stoma closure when possible.

Viewpoint: controversies surrounding use of order sets for clinical decision support in computerized provider order entry.

Order sets provide straightforward clinical decision support within computerized provider order entry systems. They make "the right thing" easier to do because they are much faster than writing single orders; they deliver real-time, evidence-based prompts; they are easy to update; and they support coverage of multiple patient problems through linkages among order sets. This viewpoint paper discusses controversies surrounding use of order sets--advantages and pitfalls, decision-making criteria, and organizational considerations, including suggestions for vendors. Order sets have the potential to improve clinician efficiency, provide real-time guidance, facilitate compliance with Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare and Medicaid Services performance measure sets, and encourage overall acceptance of computerized provider order entry, but may not do so unless these controversies are addressed.

Medication-related clinical decision support in computerized provider order entry systems: a review.

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Clinical decision support to avoid adverse drug events with anticoagulants.

Unintentional duplication or timing of anticoagulant orders leaves patients at high risk for serious adverse events. Alerts at the point of electronic order entry have the potential to mitigate this risk; however poor specificity with a high frequency of interruptions may decrease the ability of a clinician to recognize specific hazards. This poster will depict custom clinical decision support designed to prevent specific misadventures with this high risk class of medications.

The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry.

BACKGROUND: Adverse drug events (ADEs) are the most common cause of injury to hospitalized patients and are often preventable. Medication errors resulting in preventable ADEs most commonly occur at the prescribing stage. OBJECTIVES: To describe the epidemiology of medication prescribing errors averted by pharmacists and to assess the likelihood that these errors would be prevented by implementing computerized prescriber order entry (CPOE). METHODS: At a 700-bed academic medical center in Chicago, Ill, clinical staff pharmacists saved all orders that contained a prescribing error for a week in early 2002. Pharmacist investigators subsequently classified drug class, error type, proximal cause, phase of hospitalization, and potential for patient harm and rated the likelihood that CPOE would have prevented the prescribing error. RESULTS: A total of 1111 prescribing errors were identified (62.4 errors per 1000 medication orders), most occurring on admission (64%). Of these, 30.8% were rated clinically significant and were most frequently related to anti-infective medication orders, incorrect dose, and medication knowledge deficiency. Of all verified prescribing errors, 64.4% were rated as likely to be prevented with CPOE (including 43% of the potentially harmful errors), 13.2% unlikely to be prevented with CPOE, and 22.4% possibly prevented with CPOE depending on specific CPOE system characteristics. CONCLUSIONS: Prescribing errors are common in the hospital setting. While CPOE systems could improve practitioner prescribing, design and implementation of a CPOE system should focus on errors with the greatest potential for patient harm. Pharmacist involvement, in addition to a CPOE system with advanced clinical decision support, is vital for achieving maximum medication safety.