Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry.

Objective: Evaluate the impact of multi-component quality improvement for pediatric asthma care focusing on serial use of an evidence-based clinical pathway via paper order sets, pathway integration into computerized provider order entry (CPOE), use of a clinical respiratory score (CRS) and a discharge checklist. Methods: Outcomes were assessed over three intervention periods and 50 months on: time to beta-agonist and steroid first administration, frequency of readmissions and hospital length of stay. A general linear model estimated mean log(LOS) over time and between study periods. Time to discharge was transformed using the natural logarithm. Results: No improvements in time to first beta-agonist or steroid administration were observed. There was a reduction in 100-day readmissions (p = 0.008): decreasing from 7.4 to 2.1% after introduction of paper order sets and CRS (adjusted p = 0.04); to 3.9% after CPOE implementation (adjusted p = 0.53) and to 2.2% when a discharge checklist was added (adjusted p = 0.01). There was a statistically significant reduction in LOS between study periods (p = 0.015). The geometric mean LOS in hours during study periods 1-4 were: 34.8 (95% CI: 32.2, 37.6), 29.3 (95% CI: 27.5, 31.3), 29.0 (95% CI: 27.0, 31.3) and 23.1 (95% CI: 22.1, 24.2). Pair-wise comparisons between periods were statistically significant (adjusted p ≤ 0.003), except for Periods 2 and 3 (adjusted p = 0.83). Conclusions: Hospital length of stay and 100-day readmissions rate in a predominantly Hispanic, Medicaid patient population were reduced by utilization of an evidence-based best practices asthma management pathway and CRS within CPOE, combined with a checklist to expedite discharge.

The Impact of Order Source Misattribution on Computerized Provider Order Entry (CPOE) Performance Metrics.

BACKGROUND: One strategy to foster adoption of computerized provider order entry (CPOE) by physicians is the monthly distribution of a list identifying the number and use rate percentage of orders entered electronically versus on paper by each physician in the facility. Physicians care about CPOE use rate reports because they support the patient safety and quality improvement objectives of CPOE implementation. Certain physician groups are also motivated because they participate in contracted financial and performance arrangements that include incentive payments or financial penalties for meeting (or failing to meet) a specified CPOE use rate target. Misattribution of order sources can hinder accurate measurement of individual physician CPOE use and can thereby undermine providers' confidence in their reported performance, as well as their motivation to utilize CPOE. Misattribution of order sources also has significant patient safety, quality, and medicolegal implications. OBJECTIVE: This analysis sought to evaluate the magnitude and sources of misattribution among hospitalists with high CPOE use and, if misattribution was found, to formulate strategies to prevent and reduce its recurrence, thereby ensuring the integrity and credibility of individual and facility CPOE use rate reporting. METHODS: A detailed manual order source review and validation of all orders issued by one hospitalist group at a midsize community hospital was conducted for a one-month study period. RESULTS: We found that a small but not dismissible percentage of orders issued by hospitalists-up to 4.18 percent (95 percent confidence interval, 3.84-4.56 percent) per month-were attributed inaccurately. Sources of misattribution by department or function were as follows: nursing, 42 percent; pharmacy, 38 percent; laboratory, 15 percent; unit clerk, 3 percent; and radiology, 2 percent. Order management and protocol were the most common correct order sources that were incorrectly attributed. CONCLUSION: Order source misattribution can negatively affect reported provider CPOE use rates and should be investigated if providers perceive discrepancies between reported rates and their actual performance. Preventive education and communication efforts across departments can help prevent and reduce misattribution.