Implementation of an Integrated Admission Order Set to Improve Institutional Clinical Practice Guideline Adherence

From the 2021 HVPAA National Conference

Justine Mrosak (Emory University/Childrens Healthcare of Atlanta), Swaminathan Kandaswamy (Emory University School of Medicine), Claire Stokes, David Roth, Evan Orenstein

Background

Clinical practice guidelines (CPGs) help standardize care and disseminate evidence-based practices, leading to leading to decreased variation of care and improved patient outcomes. Order sets coupled to CPGs can facilitate adherence by reducing cognitive burden and making it easier to do the “right” thing. At our institution we identified several CPGs where the appropriate order set was used in <50% of eligible encounters. Barriers to order set adoption at our institution were lack of awareness, forgetting to use the order set, eligibility for multiple CPGs and confusion with non-CPG order sets with similar names. In this study, we developed an updated general pediatrics admission order set integrating CPG order bundles.

Objective

Increase CPG specific order set usage for eligible patients admitted on the general pediatrics service by 20% from July 2019 to December 2020

Methods

We developed an admission order set that incorporates a subset of our CPG order bundles (asthma, heavy menstrual bleeding, musculoskeletal infection, community acquired pneumonia and migraine) aimed at addressing barriers to adoption at our institution. Similarly named, but non-CPG order sets were identified and retired from the EHR 1/6/2020. The integrated order set was implemented into the EHR June 6, 2020. We identified encounters from 7/1/2019 through 12/31/2020 in which patients were eligible for a CPG based on pre-existing, computable population definitions. All encounters that appeared eligible but where the appropriate order set was not used were manually chart reviewed to confirm eligibility. Appropriate order set use for eligible encounters for incorporated CPGs was compared pre- and post-implementation.

Results

From July 2019 to December 2020, 1,358 encounters were identified as eligible for a CPG (1,054 pre- and 304 post-implementation). 537 (40%) encounters appeared eligible but the CPG order set was not used, 263 of these (19%) were excluded for not meeting eligibility criteria. Disease specific order set usage increased from 73% to 83% (+10.3%, 95% CI: +4.2% – +16.1%, p = 0.002) after implementation. When broken down by disease-specific CPG, there appears to be differing effect of the intervention whereas asthma and heavy menstrual bleeding had more improvement than musculoskeletal infection, migraine or pneumonia.

Conclusion

Implementation of an integrated admission order set increases overall guideline order set usage for eligible patients at our institution. Diagnostic uncertainty at the time of admission likely determines whether this intervention will be effective as diseases with relatively clear diagnoses saw greater improvement.

Clinical Relevance

Despite CPGs, many eligible patients are not managed in concordance with guideline recommendations, leading to a lower value of care. In this study, we demonstrated that incorporation of CPG order bundles into an integrated general pediatrics admission order set improved adoption of CPG order bundles. This strategy could improve use of evidence-based management strategies, decrease variation of care and improve patient outcomes in general pediatrics and other settings.

Click here to register for the 2022 Architecture of High Value Health Care National Conference!

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog