Analysis of Daily Laboratory Orders at a Large Urban Academic Center: A Multifaceted Approach to Changing Test Ordering Patterns.

OBJECTIVES: We sought to address concerns regarding recurring inpatient laboratory test order practices (daily laboratory tests) through a multifaceted approach to changing ordering patterns. METHODS: We engaged in an interdepartmental collaboration to foster mindful test ordering through clinical policy creation, electronic clinical decision support, and continuous auditing and feedback. RESULTS: Annualized daily order volumes decreased from approximately 25,000 to 10,000 during a 33-month postintervention review. This represented a significant change from preintervention order volumes (95% confidence interval, 0.61-0.64; P < 10-16). Total inpatient test volumes were not affected. CONCLUSIONS: Durable changes to inpatient order practices can be achieved through a collaborative approach to utilization management that includes shared responsibility for establishing clinical guidelines and electronic decision support. Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs.

Effectiveness of interruptive alerts in increasing application functionality utilization: a controlled trial.

Medical applications frequently contain a wide range of functionalities. Users are often unaware of all of the functionalities available. More effective ways of delivering information about available functionalities to the users are needed. We conducted a pseudo-randomized controlled trial to determine whether interruptive alerts will increase utilization of several functionalities by the users of the Pre-Admission Medication List (PAML) Builder application at two academic medical centers. In a log-linear model, alerts increased total utilization of the promoted functionalities per PAML built by 70% compared to the controls at the site level (p<0.0001). At the user level, frequency of utilization of the PAML Builder functionalities by individual users increased by 0.03 for every extra alert shown to the user (p<0.0001). Alerts led to a nearly 2-fold increase in utilization of the promoted functionalities. Interruptive alerts are an effective method of delivering information about application functionalities to users.

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

BACKGROUND: Medication reconciliation at transitions in care is a national patient safety goal, but its effects on important patient outcomes require further evaluation. We sought to measure the impact of an information technology-based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]). METHODS: We performed a controlled trial, randomized by medical team, on general medical inpatient units at 2 academic hospitals from May to June 2006. We enrolled 322 patients admitted to 14 medical teams, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. The main outcome was unintentional discrepancies between preadmission medications and admission or discharge medications that had potential for harm (PADEs). RESULTS: Among 160 control patients, there were 230 PADEs (1.44 per patient), while among 162 intervention patients there were 170 PADEs (1.05 per patient) (adjusted relative risk [ARR], 0.72; 95% confidence interval [CI], 0.52-0.99). A significant benefit was found at hospital 1 (ARR, 0.60; 95% CI, 0.38-0.97) but not at hospital 2 (ARR, 0.87; 95% CI, 0.57-1.32) (P = .32 for test of effect modification). Hospitals differed in the extent of integration of the medication reconciliation tool into computerized provider order entry applications at discharge. CONCLUSIONS: A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.

Classifying and predicting errors of inpatient medication reconciliation.

BACKGROUND: Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur. OBJECTIVE: To determine the reasons, timing, and predictors of potentially harmful medication discrepancies. DESIGN: Prospective observational study. PATIENTS: Admitted general medical patients. MEASUREMENTS: Study pharmacists took gold-standard medication histories and compared them with medical teams' medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs). RESULTS: Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs. CONCLUSIONS: Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.

Evaluation of an inpatient computerized medication reconciliation system.

We designed the Pre-Admission Medication List (PAML) Builder medication reconciliation application and implemented it at two academic hospitals. We asked 1,714 users to complete a survey of their satisfaction with the application and analyzed factors associated with user efficiency. The survey was completed by 626 (36.5%) users. Most (64%) responders agreed that medication reconciliation improves patient care. Improvement requests included better medication information sources and propagation of medication information to order entry. Sixty-nine percent of admitting clinicians reported a typical time to build a PAML of <10 min. Decreased reported time to build a PAML was associated with reported experience with the application and ease of use but not the average number of medications on the PAML. Most users agreed that medication reconciliation improves patient care but requested tighter integration of the different stages of the medication reconciliation process. Further training may be helpful in improving user efficiency.

The use of electronic medication reconciliation to establish the predictors of validity of computerized medication records.

Medication records in clinical information systems (CIS) are frequently inaccurate, leading to potentially incorrect clinical decisions and preventing valid decision support interventions. It is not known what characteristics of electronic medication records are predictive of their validity. We studied a dataset of 136,351 electronic medication records of patients admitted to two academic hospitals that were individually validated by admitting providers using novel medication reconciliation software. We analyzed the relationship between characteristics of individual medication records and the probability of record validation using a multivariable linear regression model. Electronic medication records were less likely to be validated if more time had passed since their last update (14.6% for every 6 months), if they represented an antiinfective (61.6%) or a prn (50.9%) medication, or if they were in an outpatient CIS rather than on an inpatient discharge medication list (18.1%); p<0.0001 for all. Several characteristics of electronic medication records are strongly associated with their validity. These findings could be incorporated in the design of CIS software to alert providers to medication records less likely to be accurate.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.

Upper extremity musculoskeletal symptoms and functional impairment associated with computer use among college students.

PURPOSE: Occupational computer use has been associated with upper extremity musculoskeletal disorders among working-age adults, but little is known about computer-related musculoskeletal problems among college students. We carried out a descriptive epidemiological study of computer use-associated symptoms, functional limitations, and medication and health care utilization in this population. SUBJECTS AND METHODS: Cross-sectional survey of 240 undergraduates in the second through fourth years at a residential dormitory at a four-year college with random housing assignments. RESULTS: 194 students returned useable surveys (81% response rate). 42% reported upper extremity pain or discomfort when using a computer in the preceding two weeks. 41% said this pain or discomfort caused functional limitation and 9% said that these symptoms hindered academic or extracurricular performance. 23% reported taking medications for upper extremity pain related to computing (4% regularly) and 16% had seen a health care provider for computer-related symptoms. Female students, students of racial/ethnic minority groups, and students who experienced symptoms with < or = 1 hour of computer use were more likely to report symptom-related functional limitation than others. CONCLUSION: College students report high rates of computer use-associated upper extremity musculoskeletal symptoms and symptom-related functional limitation. Future studies should more closely examine exposure, demographic, and ergonomic correlates of these symptoms and outcomes.

Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: To our knowledge, no previous study has systematically examined pneumonia-related and pneumonia-unrelated mortality. This study was performed to identify the cause(s) of death and to compare the timing and risk factors associated with pneumonia-related and pneumonia-unrelated mortality. METHODS: For all deaths within 90 days of presentation, a synopsis of all events preceding death was independently reviewed by 2 members of a 5-member review panel (C.M.C., D.E.S., T.J.M., W.N.K., and M.J.F.). The underlying and immediate causes of death and whether pneumonia had a major, a minor, or no apparent role in the death were determined using consensus. Death was defined as pneumonia related if pneumonia was the underlying or immediate cause of death or played a major role in the cause of death. Competing-risk Cox proportional hazards regression models were used to identify baseline characteristics associated with mortality. RESULTS: Patients (944 outpatients and 1343 inpatients) with clinical and radiographic evidence of pneumonia were enrolled, and 208 (9%) died by 90 days. The most frequent immediate causes of death were respiratory failure (38%), cardiac conditions (13%), and infectious conditions (11%); the most frequent underlying causes of death were neurological conditions (29%), malignancies (24%), and cardiac conditions (14%). Mortality was pneumonia related in 110 (53%) of the 208 deaths. Pneumonia-related deaths were 7.7 times more likely to occur within 30 days of presentation compared with pneumonia-unrelated deaths. Factors independently associated with pneumonia-related mortality were hypothermia, altered mental status, elevated serum urea nitrogen level, chronic liver disease, leukopenia, and hypoxemia. Factors independently associated with pneumonia-unrelated mortality were dementia, immunosuppression, active cancer, systolic hypotension, male sex, and multilobar pulmonary infiltrates. Increasing age and evidence of aspiration were independent predictors of both types of mortality. CONCLUSIONS: For patients with community-acquired pneumonia, only half of all deaths are attributable to their acute illness. Differences in the timing of death and risk factors for mortality suggest that future studies of community-acquired pneumonia should differentiate all-cause and pneumonia-related mortality.

Community-acquired pneumonia and do not resuscitate orders.

OBJECTIVES: From a cohort of patients with community-acquired pneumonia (CAP) who required admission to hospital, to describe the subset of patients having a do not resuscitate (DNR) order and to compare them with those who did not have such an order. DESIGN: Retrospective subset analysis of data from the pneumonia patient outcomes research team study. SETTING: Three hospitals in the United States and one in Canada. PARTICIPANTS: Hospitalized patients aged 18 and older with CAP. MEASUREMENTS: Sociodemographic features, severity of illness, antibiotic therapy, length of stay, mortality, admission to special care units, and mortality attributable to pneumonia. RESULTS: The 199 (14.9) of 1,339 inpatients with CAP who had a DNR order written within 24 hours of admission and an additional 96 (7.2) patients who had such an order written later were compared with the 1,044 who never had a DNR order. The 199 patients with an initial DNR and 96 later DNR were older (median age 81 and 78 vs 65 years, respectively; P< .001), more likely to be white (92.5 and 90.6 vs 84.8; P = .007), and more likely to have come from a nursing home or chronic care facility (53.8 and 31.3 vs 4.5; P< .001). The two DNR groups received more antibiotics for a longer time than the never DNR patients. The DNR patients had longer lengths of stay than the never DNR patients (medians 9 and 12 vs 7 days). There were 89 in-hospital deaths among the 1,339 patients, but only 11 of these were among patients who did not have a DNR order during the first 30 days (sensitivity, specificity, and positive and negative predictive values of a DNR order for in-hospital mortality were 87.6, 82.6, 26.4, and 98.9, respectively). The 90-day mortality rates were 43.2 for the initial DNR group, 61.5 in the later DNR group, and 4.7 for the never DNR group (P< .001). Pneumonia-attributable mortality accounted for most of the in-hospital deaths but did not differ by DNR status. Only 31.7 of the initial DNR patients and 24.0 of the later DNR patients were discharged home, versus 82.6 of the other patients (P< .001). In a multivariate analysis, the following were predictive of initial DNR: age, nursing home care, active cancer, dementia, neuromuscular disorders, altered mental status, low systolic blood pressure, tachypnea, abnormal hematocrit, abnormal blood urea nitrogen, and absence of alcohol or intravenous drug abuse. In similar analyses of DNR at any time, additional predictors included aspiration, low white blood count, chronic pulmonary disease, cerebrovascular disease, and congestive heart failure. CONCLUSION: Most in-hospital pneumonia deaths occur in patients who have a DNR order. DNR orders written within 24 hours of admission primarily reflect comorbid status, whereas DNR orders written later during hospitalization reflect the futility of care plus comorbidity.

Assessment of upper extremity role functioning in students.

BACKGROUND: Upper extremity symptoms associated with use of computers and other upper extremity activities are common in students. Research on these disorders requires psychometrically sound measures of health-related student role function; no such measure is available currently. METHODS: Based upon input from students and clinicians, we developed a 10-item scale to measure student health-related role function. The measure was administered as part of a survey of 193 undergraduates at one university. A follow-up survey was administered 1 month later. The student health-related role function questionnaire was assessed for internal consistency, ceiling effects, convergent and discriminant validity, and responsiveness to self-reported change in functional status. RESULTS: Eighty-two percent of students who were given the survey completed it and 65% completed a follow-up survey 1 month later. The new measure was reliable (Cronbach's alpha 0.87). Forty-six percent of respondents reported "no difficulty" on all items of the health-related student role function measure while 64% reported "no difficulty" on all items of a generic upper extremity functional status measure. This finding indicates that the new measure was better able to detect functional limitations; it had a less prominent ceiling effect. The new measure had moderately high correlations with measures of symptom severity and pain, documenting convergent validity. It distinguished students who utilized clinician services, medications, or academic accommodation from students who did not utilize these resources, documenting discriminant validity. The measure was responsive to self-perceived change, as demonstrated by a highly significant association (P < 0.0001) between changes in score over a 1-month follow-up and students' perceptions of whether they had improved in functional abilities after the month, deteriorated or remained stable. CONCLUSIONS: The student health-related role functioning measure is reliable, valid and responsive to change. It is an appropriate measure for research on upper extremity symptoms in students.