Development and Implementation of an Inpatient Order Set to Reduce Wasteful Recurring Orders

From the 2023 HVPA National Conference

Aishwarya Katiki MS, BS (University of Chicago Pritzker School of Medicine), Vanshika Narala BS, Khanh Nguyen MD, BS, Matthew Cerasale MD, BS, Caleb Murphy MD

Background:
Many electronic medical records (EMR) allow automated recurring orders for a variety of inpatient interventions, including lab tests, vital signs, and telemetry monitoring. As patients stabilize throughout hospitalization, however, the frequency and intensity of these orders often remain unchanged. Well-designed EMR order sets have potential to mitigate resource overutilization in stable patients.

Objective:
To develop and evaluate a new hospitalist order set to facilitate ongoing review and de-intensification of hospital care in clinically stable patients.

Methods:
Literature review coupled with team discussion and section feedback were used to identify hospital care components prone to overuse in stable patients. The final list of targeted care components included electrolyte panels, complete blood counts (CBCs), vital sign checks, telemetry monitoring, continuous pulse oximetry, indwelling bladder catheterization, nebulized bronchodilators, point-of-care glucose checks, and alcohol withdrawal monitoring. An Epic order set was then designed by our team’s Epic EMR physician builder to offer options to discontinue these interventions or re-order them at a lower frequency (Figure 1).

The order set was promoted to hospitalists via section-wide emails, WhatsApp messages, and announcements at section meetings. Primary outcomes were orders for daily electrolyte panels, daily CBCs, Q4H vital sign checks, and line/tether utilization (a composite of telemetry, continuous pulse oximetry, Foley catheter, and nebulized bronchodilators) per hospital day among low-acuity general medicine inpatients. As a balancing measure, recurring electrolyte panel orders of any frequency were also monitored. Data was collected twice weekly for a 2.5-month pre-intervention period and 1.5-month intervention period.

Results:  
Number of patient-days analyzed were 716 for pre-intervention and 440 for during the intervention period. The order set was used in 36 separate encounters (8.2%) during the intervention period. There was a significant decrease in the number of high-frequency vital sign orders per low-acuity patient day between the pre-intervention and intervention periods (0.83 vs 0.66, respectively; P<.001). There were 27 unique orders to decrease vital sign frequency placed through the order set, accounting for 46% of the reduction seen (226 post-intervention orders compared to an expected 285). No pre/post-intervention difference was observed for daily electrolyte panel orders (0.45 vs 0.47, P=.22), daily CBC orders (0.43 vs 0.45, P=.34), or line/tether orders (0.33 vs 0.33, P=.49) per patient day. There was no pre/post intervention difference in recurring electrolyte panel orders of any frequency (0.53 vs 0.61, P=.16).

Conclusion:
Early results from this intervention indicate that a novel order set combined with a public awareness campaign may be an effective approach to reduce utilization of some hospital resources in stable inpatients. The next steps are to continue promoting the order set and implementing automated reminders for providers to use the order set in stable patients.

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